All citations for The Estates at Excelsior LLC

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to The Estates at Excelsior LLC

Last standard health inspection on record

April 7, 2026

Showing 1 to 25 of 53 citations

  1. Immediate jeopardy to resident health or safety

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level L.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of July 9, 2026. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (July 8, 2026).

  2. Immediate jeopardy to resident health or safety

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Widespread (many residents). CMS level L.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of July 9, 2026. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (July 8, 2026).

  3. Immediate jeopardy to resident health or safety

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of November 26, 2025. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (November 17, 2025).

  4. No harm, with potential for more than minimal harm

    Meet requirements for the installation and maintenance of electrical systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0911, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  5. No harm, with potential for more than minimal harm

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    Widespread (many residents). CMS level F.

    Health citation F-0809, Nutrition and Dietary Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  6. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  7. No harm, with potential for more than minimal harm

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Widespread (many residents). CMS level F.

    Health citation F-0865, Administration Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  8. No harm, with potential for more than minimal harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Widespread (many residents). CMS level F.

    Health citation F-0867, Administration Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  9. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  10. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  11. No harm, with potential for more than minimal harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Widespread (many residents). CMS level F.

    Health citation F-0867, Administration Deficiencies. Inspection of May 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 18, 2024).

  12. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 7, 2024).

  13. No harm, with potential for more than minimal harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0757, Pharmacy Service Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  14. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  15. No harm, with potential for more than minimal harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0565, Resident Rights Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  16. No harm, with potential for more than minimal harm

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0628, Resident Rights Deficiencies. Inspection of June 16, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  17. No harm, with potential for more than minimal harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of June 16, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 30, 2025).

  18. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of May 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 18, 2024).

  19. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of May 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 18, 2024).

  20. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of May 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 7, 2024).

  21. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  22. No harm, with potential for more than minimal harm

    Allow residents to self-administer drugs if determined clinically appropriate.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0554, Resident Rights Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  23. No harm, with potential for more than minimal harm

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0557, Resident Rights Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  24. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

  25. No harm, with potential for more than minimal harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0676, Quality of Life and Care Deficiencies. Inspection of April 7, 2026. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 22, 2026).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.