The Estates at Excelsior LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice, including failure to document clinical indications for medications, failure to monitor medications as ordered (including failure to monitor heart rate parameters prior to medication administration), and failure to ensure PRN psychotropic medications had appropriate stop dates, for 5 of 6 residents (R2, R5, R6, R16, and R26) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure a catheter bag containing urine was concealed from public view for 1 of 3 residents (R3) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were assessed, determined safe to self-administer medications, and that self-administration practices were consistently implemented in accordance with physician orders and facility policy for 2 of 2 residents (R22 and R17) reviewed for self-administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to make choices regarding her living environment and personal possessions was honored by removing items from her room without prior notice and by failing to follow care plan interventions and ACP recommendations for 1 of 1 resident (R22) reviewed for resident rights.

Inspectors wroteBased on interview and document review the facility failed to revise and update comprehensive care plan for 2 of 5 residents (R7 and R30) reviewed for comprehensive care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance and/or cueing with activities of daily living, including grooming, dressing and maintaining personal hygiene, for 2 of 2 residents (R13, R16) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe mobility and transportation of a resident by staff, resulting in the risk for injury, for 1 of 1 residents (R26) reviewed for quality of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a functional maintenance program (FMP) was implemented to maintain the resident's highest practicable level of functioning, as recommended by therapy services, for 1 of 1 resident (R28) reviewed for rehabilitation and restorative nursing services.

Inspectors wroteBased on record review and interview, the facility failed to ensure a thorough post-fall assessment, including root cause analysis, was completed and appropriate interventions were implemented and reflected in the care plan following repeated falls, for 1 of 2 resident (R2) reviewed for accidents.

Inspectors wroteBased on document review and interview, the facility failed to ensure pneumococcal immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents (R27) reviewed for immunizations.

Inspectors wroteBased on document review and interview the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standards of practice for 1 of 5 residents (R27) reviewed for immunizations.

Inspectors wroteBased 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. The immediate jeopardy began on 11/14/25, when the DON responded to a resident biting her with physical and verbal abuse, the facility did not recognize this as abuse until 11/16/25, when the witness called the administrator to recant her original statement regarding the DON's actions towards R1. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 3 of 3 sampled staff (housekeeping aide (HA)-A, speech therapist (ST)-A, and certified nursing assistant (NA)-A. This had the potential to affect all 35 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to act promptly and provide resolution for resident concerns related to the dietary department failure to post upcoming menus.

Inspectors wroteR27's 4/24/25, 14-day admission assessment, MDS identified her cognition was intact, and she required supervision to moderate assistance with activities of daily living, (ADLS). Her diagnosis list included ataxia, (impaired balanced or coordination), weakness, COPD, chronic back pain, and paranoid schizophrenia. R27's medical record identified MDS assessment: 1)4/8/25 entry tracking record 2) 4/13/25 discharge with return anticipated, with a 4/18/25 entry tracking record 3) 4/24/25 14-day admission assessment Review of R27's Hospital after visit summary identified she was hospitalized [DATE] through 4/18/25 with acute midline low back pain with right-sided sciatica, ((pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). R27's 4/13/25 at 10:35 p.m. progress note identified she had called 911 from her room with complaints of back pain. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide for Activities of Daily Living (ADL) related to assisting with toileting, turning and repositioning, queuing for food and hydration needs, and assisting with personal hygiene for 4 of 7 sampled dependent residents (R2, R7, R24, and R137).

Inspectors wroteBased on interview and document review the facility failed to ensure Notice of Medicare Non- Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) was given to the resident's representative for signature for 1 of 4 residents (R139) with known cognitive impairment.

Inspectors wroteR18's 4/9/25, quarterly Minimum Data Set (MDS) assessment identified R18's cognition was intact, R18 was dependent on staff for transfers and R18 attended dialysis. R18's care plan identified R18 had nutritional risk for malnutrition related chronic disease. R18 required increased protein related to end stage renal disease (ESRD), required a fluid restriction of 1200 milliliters (ml). R18 would receive supplements and be offered a liberalized diet. Staff were to communicate with renal dietician at dialysis, and explain and reinforce the importance of maintaining the diet ordered. The facility staff would provide and serve R18's diet as ordered, a modified renal, large portions, and a 1200 fluid restriction with snacks between meals three times a day. Observation and interview on 6/9/25 at 5:30 p.m., R18 was observed in his bed with his evening meal on the bedside table in front of him. [...]

Inspectors wroteR7 R7's 3/26/25, quarterly Minimum Data Set (MDS) identified his cognition was intact, he felt down and depressed 2-6 days weekly, and had no behaviors. R7 required the use of a wheelchair, he was frequently incontinent of urine and occasionally incontinent of bm. He had diagnosis of seizures, anxiety, and depression, and received antipsychotics on a routine basis. R7's current care plan identified he had a diagnosis of major depressive disorder and generalized anxiety disorder. The focus was for R7 to remain stable and R7 to respond to interventions by staff to calm and redirect. the interventions were to complete assessments, redirect as needed, and provide emotional support. The care plan lacked any individualized target behaviors staff should be monitoring for. [...]

Inspectors wroteBased on interview and document review, the facility failed to complete a 48 hour baseline care plan upon admission for 1 of 10 residents (R187) reviewed.

Inspectors wroteThe facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 sampled residents (R5) that addressed anticoagulant (prevents and breaks down blood clots) therapy with safety precautions.

Inspectors wroteBased on interview and document review, the facility failed to revise the care plan to reflect current care needs for 2 of 13 sampled residents (R2 and R18) reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to identify appropriate turning and repositioning schedule based off professional standards of practice and document when staff performed repositioning for 1 of 2 residents (R32) who has a pressure ulcer and to minimize the risk of further pressure ulcer development and ensured interventions were implemented.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide a prescribed therapeutic diet to 1 of 1 resident (R18) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to implement their dialysis contract and arrange for transportation to dialysis for 1 of 1 resident (R18) who missed their regularly scheduled ride service for dialysis treatment.

Inspectors wroteBased on interview and document review, the facility failed to ensure supply and administration of ordered medications for 1 of 1 resident (R24) reviewed for pharmacy services.

Inspectors wroteBased on observation, interview, and document review the facility failed to offer an alternative food item for 1 of 1 residents (R187).

Inspectors wroteBased on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 (R24 and R238) sampled residents reviewed for antibiotic stewardship.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 (R5) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC).

Inspectors wroteBased on interview and document review, the facility failed to implement the use of an air pressure redistribution mattress to aid in providing pressure ulcer relief for 1 of 3 residents (R1) reviewed for pain management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement appropriate personal protective equipment (PPE) to prevent the spread of infection for 1 of 1 residents (R2) observed for enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted masks, gown and glove use during high contact resident care activities).

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance Process Improvement (QAPI) committee was effective in maintaining appropriate action plans to correct a quality deficiency identified during a previous survey related to infection control practices for indwelling foley catheters which resulted in a deficiency identified during this survey:

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure insulin pens were appropriately labeled according to manufacturer's guidelines with an opened date in 1 of 2 medication carts(North) for 2 of 2 residents (R20, R22) whom required use of an insulin pen. In addition, the facility failed to ensure three bottles of eye drops were appropriately labeled with an open date to prevent expired eye drops from being administered. This deficient practice affected 1 of 2 medication carts reviewed for storage and 5 of 5 residents (R1, R12, R20, R22 and a previously discharged resident) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene during wound cares for 1 of 1 resident (R15), failed to ensure proper personal protective equipment (PPE) for 2 of 2 residents (R331, R5), and failed to ensure proper placement of foley catheter bag and cleaning with catheter cares for 1 of 1 resident (R4) reviewed for infection control.

Inspectors wroteBased on record review and interview, the facility failed to provide a written notification/copy of a bed hold for 2 of 2 (R1, R20) residents reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 resident (R5) were offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of staff to resident abuse was reported immediately (within two hours) to the State Agency (SA) for 1 of 3 residents (R1) reviewed for abuse.