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Deficiency Records for The Estates at Excelsior LLC
A list of the most recent deficiencies for The Estates at Excelsior LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Estates at Excelsior LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-16 | 2024-06-18 | N |
| 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. | Health | 2024-05-16 | 2024-06-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-16 | 2024-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-16 | 2024-06-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-16 | 2024-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-14 | 2024-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-14 | 2024-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-25 | 2024-05-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-08-11 | 2023-09-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-11 | 2023-09-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-11 | 2023-09-01 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-30 | 2023-08-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-02 | 2023-07-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-02 | 2023-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-02 | 2023-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-02 | 2023-07-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-02 | 2023-07-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-06-02 | 2023-07-28 | N |
| 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. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-06-02 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-02 | 2023-07-28 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-02 | 2023-07-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-02 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-30 | 2023-07-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-04-20 | 2022-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-20 | 2022-06-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-20 | 2022-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-20 | 2022-06-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-20 | 2022-06-20 | N |
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