Majestic Center for Rehab & Sub-Acute Care

Inspectors wroteBased on interview, and record review it was determined the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed accurately for a newly admitted resident. This deficient practice was identified in 1 of 4 residents reviewed for PASARR (Resident #98) and was evidenced by the following: On 12/15/25 at 10:42 AM, the surveyor reviewed Resident #98's Electronic Medical Record (EMR) which showed that the resident had a PASARR Level I screening, dated 11/11/25, which was completed on entry to the facility. Under Section II for diagnoses of mental illness, it was marked as NO, meaning Resident #98 did not have any mental illness diagnoses. A review of the admission Record (admission summary) reflected Resident #98 had diagnoses which included, but were not limited to, major depressive disorder and bipolar disorder. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to discard potentially hazardous foods past their Best by date from the storage room to prevent foodborne illness; b.) to ensure that the dish machine maintained an adequate chemical sanitizer level, and c.) to ensure that the oven was maintained in a clean and sanitary manner. This deficient practice was evidenced by the following: On 6/27/2025 9:51 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: 1.) In the dry storage room, a brown box containing twenty-four single, one-pound bags of black-eyed peas, with the Best By date 9/29/24. The FSD pulled the box from the shelf and confirmed the findings. He then stated that he would discard the box of black-eyed peas. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure the food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficient practice was identified for seven (7) of 24 residents (Resident #17, #18, #19, #22, #26, #48, and #104). This deficient practice was evidenced by the following 1.) On 6/30/2025 at 10:30 AM, the surveyor conducted a resident council meeting. During that meeting, five (5) out of 5 residents (Resident #17, #19, #26, #48, and #104) stated that their food was not served hot. 2.) On 7/1/2025 at 11:34 AM, the surveyor observed the food service distribution line in the kitchen: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a Bi-level positive airway pressure (BiPap machine, a non-invasive ventilation machine that helps you to breathe and delivers air through a face mask in a timely manner to accommodate the respiratory needs of a resident in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #317) reviewed for respiratory care and was evidenced by the following: On 6/27/25 at 11:11 AM, during the initial tour of the facility, the surveyor observed Resident #317 ambulating in their room on four (4) liters of non-humidified oxygen via an oxygen concentrator (a medical device that extracts oxygen from the air). [...]

Inspectors wrotePART A: NJ Complaint #: 163766 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to (a) ensure there was emergency tracheostomy equipment for a resident with a tracheostomy (a surgical opening in the neck to provide an airway and remove secretions from the lungs), and (b) ensure staff were trained to use the emergency equipment in case of displacement of the tracheostomy tube for one (1) of 1 resident (Resident #313) reviewed with a tracheostomy. Resident #313 was admitted to the facility with a tracheostomy (trach). A review of the Progress Notes revealed that the resident was sent to the hospital on two occasions, on 03/30/23 for not having tracheostomy supplies, and on 04/6/23 for decannulation (removal) of the trach. [...]

Inspectors wroteComplaint #: NJ169862 Based on observations, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to: 1) develop and implement a comprehensive policy to maintain a system of accountability for the back up storage of controlled medications ( drugs that are tightly controlled by the government because of the risk of abuse and addiction) 2) store insulin pens (a device used to inject insulin to reduce blood sugar levels in persons with diabetes) in a safe and sanitary manner to prevent the spread of infection, and 3) administer a medication used to treat high blood pressure (Labetalol HCL (hydrochloride)) in a timely manner in accordance with the facility policy and professional standards of nursing practice. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 residents (Resident #36) reviewed for Beneficiary Protection Notification. The deficient practice was evidenced by the following: The facility presented the surveyor with a list of residents who were discharged from the facility within six (6) months and should have received Beneficiary Notices. On 9/26/24 at 12:00 PM, the surveyor requested three (3) random residents', one (1) resident who went home and two (2) residents who remained in the facility, beneficiary notification forms from the Director of Nursing (DON). [...]

Inspectors wroteBased on interviews, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure a) licensed staff credentials were verified upon hire (Staff #2 and #9), and reference checks were completed. This deficient practice was identified for 8 of 10 employee files reviewed (Employee #4, #6, #7, #8, #9 and #10) and was evidenced by the following: 1.) Staff #2, a Licensed Practical Nurse (LPN), with a date of hire 8/1/24, the employee file contained a copy of their licensure, however did not have a license verification printout in the employees file. There was no documented evidence that Staff #2's license was verified. Staff #9, an Occupation Therapist (OT), with the hire date 10/13/23, the employee file did not contain a copy of the license. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop a comprehensive person-centered care plan for 1 of 24 residents (Resident #26) reviewed. This deficient practice was evidenced by the following: A review of the admission Record (an admission summary) revealed Resident #26 had diagnoses which included, but were not limited to, open wound left foot, non-pressure chronic ulcer of other part of left foot, acute osteomyelitis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anxiety Disorder, Major Depressive Disorder, and Post Traumatic Stress Disorder Upon review of the Electronic Medical Record (EMR), there was no evidence that the Comprehensive Care Plan was completed. [...]

Inspectors wroteBased on observations, interviews, and review of other pertinent documentation, it was determined that the facility failed to administer medications in accordance with physician's orders and professional standards of nursing clinical practice. This deficient practice was identified during the medication pass observation for 1 of 2 nurses on 1 of 2 nursing units (Two West). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interviews, record review and review of other pertinent information, it was determined that the facility failed to ensure dietary assessments were conducted in a timely manner for a resident with a feeding tube who experienced weight loss. This deficient practice was identified for 1 of 1 resident (Resident #27) reviewed for tube feeding. This deficient practice was identified by the following: On 09/27/24 at 12:57 PM, the surveyor observed Resident #27 lying in bed awake. The resident had a tube feeding (artificial nutrition delivered through a tube that is surgically inserted into the stomach) pump that hung on a pole beside the resident's bed that was not in use at the time of the observation. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that all certified nursing staff hired by the facility had certifications in good standing. This deficient practice occurred to 2 of 10 newly hired CNAs (certified nurse aides), (Employees #3 and #8) that were newly hired. This deficient practice was evidenced by the following: On 10/1/24 at 1:32 PM, the surveyor reviewed the employee files of 10 randomly selected CNAs that was recently hired. The following was revealed: A review of the employee file for Employee #3 with a hire date of 9/19/24, did not contain evidence that her certification was verified prior to employment. A review of the employee file for Employee #8 with a hire date of 7/6/23, did not contain evidence that her certification was verified prior to employment. [...]