Deficiency Records for Majestic Oaks Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Majestic Oaks Rehabilitation and Nursing Center. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-31 | 2023-09-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-30 | 2023-08-24 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-06-30 | 2023-08-24 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-06-30 | 2023-08-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-30 | 2023-08-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-08-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-30 | 2023-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-08-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-30 | 2023-08-24 | 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 | 2023-06-30 | 2023-08-24 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-30 | 2023-08-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-30 | 2023-08-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-30 | 2023-08-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-30 | 2023-08-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-30 | 2023-08-24 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-30 | 2023-08-24 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-06-30 | 2023-08-24 | Y |
| 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 | 2023-06-30 | 2023-08-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-30 | 2023-08-24 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-30 | 2023-08-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-30 | 2023-08-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-30 | 2023-08-24 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-21 | 2022-12-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-21 | 2022-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-21 | 2022-11-08 | 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 | 2022-10-19 | 2022-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-19 | 2022-11-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-19 | 2022-11-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-13 | 2022-10-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-13 | 2022-10-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-13 | 2022-10-25 | 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 | 2022-09-13 | 2022-10-25 | 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 | 2022-09-13 | 2022-10-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-13 | 2022-10-25 | N |
| Keep all essential equipment working safely. | Health | 2022-09-13 | 2022-10-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-13 | 2022-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-24 | 2022-09-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-24 | 2022-09-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-24 | 2022-09-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-22 | 2022-07-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-22 | 2022-07-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-22 | 2022-07-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-22 | 2022-07-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-22 | 2022-07-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-22 | 2022-07-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-31 | 2022-06-18 | Y |
| 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 | 2022-05-31 | 2022-06-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-31 | 2022-06-18 | Y |
| 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 | 2022-04-27 | 2022-06-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-27 | 2022-06-04 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Meet other general requirements. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-28 | 2021-11-30 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-09-29 | 2021-11-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-09-29 | 2021-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-29 | 2021-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-29 | 2021-11-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-29 | 2021-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-29 | 2021-11-05 | 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 | 2021-09-29 | 2021-11-05 | 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 | 2021-09-29 | 2021-11-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-29 | 2021-11-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-29 | 2021-11-05 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-09-29 | 2021-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-29 | 2021-11-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-29 | 2021-11-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-08-13 | Y |
| 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 | 2021-06-14 | 2021-08-13 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-14 | 2021-08-13 | Y |
| 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 | 2022-12-13 | Not Fixed | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-13 | Not Fixed | Y |
