The Estates at Excelsior LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Excelsior LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 26, 2025

  Based on interviews and documentation review the facility failed to protect 1 of 1 resident (R1) from abuse, when R1 bit the director of nursing (DON). DON responded by pushing R1 on the bed, struggling with her until physically separated by nursing assistant (NA)-A and licensed practical nurse (LPN)-A. Then the DON rushed back in the room and pushed R1 down a second time and yelled out profanity and threatened to make R1's life a living hell. R1 suffered a bruise and pain to her left chest and shoulder. In addition, R1 had increased anxiety and fear of the DON returning to the facility. […]

• No harm, potential for more than minimal, widespreadF809Jun 16, 2025

  Based on observation, interview, and document review, the facility failed to offer a snack to residents on a routine basis when meals were greater than 14 hours apart. This had the potential to affect all 35 residents residing at the facility. Findings include: R187's 6/5/25, admission Minimum Data Set (MDS) assessment identified her cognition was intact and had no behaviors. R187 was independent with transfers, required assistance from staff with hygiene, and was occasionally incontinent of urine. She had diagnosis of heart failure, diabetes, and COPD. She was at risk for pressure ulcers and took insulin daily. Review of R187's baseline care plan identified she required assistance with bathing, dressing, hygiene, mobility, and transfers. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2025

  Based on observation and interview, the facility failed to ensure infection control practices were maintained in the kitchen when 1 of 1 staff were observed eating in the facility food preparation area. This had the ability to affect all 35 residents. Findings include: Observation on 6/11/25 at 7:28 a.m., of cook-A in the kitchen leaning over the food preparation counter near the microwave eating a sub sandwich. On the counter was a plate with food on it. Cook-A finished her sandwich, crumpled up a wrapper that said Subway on it and sat it on the hot holding steam table counter. Interview on 6/11/25 at 1:06 p.m., with the dietary manager identified staff should not be eating in the kitchen. […]

• No harm, potential for more than minimal, widespreadF865Jun 16, 2025

  Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 35 residents. Findings include: Review of the QAPI meeting minutes from March 2025 through May 2025 that was provided, identified department heads were bringing data forth to QAPI on various topics such as; pressure injuries which was above national average, falls with trends identified, psychoactive medications, activities of daily living (ADL)'s assistance with a sharp increase in help needed, infection control with an upward trend of antibiotics identified, hospitalizations with 6… […]

• No harm, potential for more than minimal, widespreadF867Jun 16, 2025

  Based on interview and document review, the facility failed to have evidence of a goal, an action plan, and analysis of data brought forth for the identified Performance Improvement Projects (PIP). This had the potential to affect all 35 residents residing at the facility. Findings include: Review of QAPI minutes provided from March 2025 through May 2025 identified the facility PIP plan for 2025 as follows: March 2025: 1) Call light response times, a trend had been identified. The facility was going to initiate call light audits, identify a root cause, and provide staff education. The director of nursing and nurse manager would provide oversight. There was no goal identified. […]