Skip to main content

Inspection visit

Health inspection

The Estates at Excelsior LLCCMS #2453329 citations on this visit
9 citations recorded

Citations

9 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0554GeneralS&S Dpotential for harm

    F554 - The right to self-administer medications if the interdisciplinary team, as

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

  • 0561GeneralS&S Dpotential for harm

    F561 - Self-determination

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    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.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0801GeneralS&S Cno actual harm

    F801 - Staffing

    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.

  • 0826GeneralS&S Epotential for harm

    F826 - Qualifications

    Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

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

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the June 2, 2023 survey of The Estates at Excelsior LLC?

This was a inspection survey of The Estates at Excelsior LLC on June 2, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at The Estates at Excelsior LLC on June 2, 2023?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Share this reportEmail

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.