A list of the most recent deficiencies for Majestic Care of Jefferson Pointe. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-14 | 2024-02-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-14 | 2024-02-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-17 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-27 | 2023-11-14 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-27 | 2023-11-14 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-27 | 2023-11-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-27 | 2023-11-14 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-10-03 | 2023-10-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-03 | 2023-09-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-09 | 2023-08-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-06-07 | 2023-07-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-09 | 2023-06-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-24 | 2023-06-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-24 | 2023-06-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-24 | 2023-06-12 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-02-09 | 2023-02-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-01 | 2023-02-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-20 | 2023-02-03 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-01-20 | 2023-02-03 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-01-20 | 2023-02-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-08-16 | 2022-09-02 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-25 | 2022-09-02 | N |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2022-05-05 | 2022-06-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-05 | 2022-06-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-28 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-05 | 2022-06-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-08 | 2022-06-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-09 | 2022-06-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-09 | 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 | 2022-06-09 | 2022-06-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-09 | 2022-06-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-29 | 2022-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-29 | 2022-04-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-29 | 2022-04-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-29 | 2022-04-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-28 | 2022-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-28 | 2022-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-28 | 2022-02-14 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-01-28 | 2022-02-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-28 | 2022-02-14 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Develop a communication plan. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-21 | 2021-05-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-16 | 2021-05-04 | N |
| Post nurse staffing information every day. | Health | 2021-04-16 | 2021-05-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-16 | 2021-05-04 | 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 | 2021-04-16 | 2021-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-16 | 2021-05-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-16 | 2021-05-04 | N |
