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.
Last standard health inspection on record
April 7, 2026
Showing 1 to 25 of 42 citations
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.
Past non-compliance: already corrected by the time of the inspection (November 17, 2025).
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.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (July 30, 2025).
No harm, with potential for more than minimal harm
Have a plan that describes the process for conducting QAPI and QAA activities.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (July 30, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (June 18, 2024).
No harm, with potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
The home gave a date the problem would be corrected (May 22, 2026).
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.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (July 30, 2025).
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.
The home gave a date the problem would be corrected (June 18, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (June 18, 2024).
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.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Allow residents to self-administer drugs if determined clinically appropriate.
The home gave a date the problem would be corrected (May 22, 2026).
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.
The home gave a date the problem would be corrected (May 22, 2026).
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.
The home gave a date the problem would be corrected (May 22, 2026).
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.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
The home gave a date the problem would be corrected (May 22, 2026).
No harm, with potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
The home gave a date the problem would be corrected (July 30, 2025).
No harm, with potential for more than minimal harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The home gave a date the problem would be corrected (July 30, 2025).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.