Majestic Oaks Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in one of the three nursing units observed (4th floor Nursing Units).

Inspectors wroteBased on clinical record reviews, interviews with residents and staff and reviews of residents' menus and dietary policies and procedures, it was determined that the facility failed to ensure that a suitable nourishing snack was provided in the evening for 10 of 10 residents reviewed. (Residents: R26, R65, R23, R66, R84, R81, R104, R26, R121 and R112)

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to ensure that advanced directives were accurately reflected in residence records for two of 31 residents reviewed (Resident R6 and Resident R9).

Inspectors wroteBased on clinical record reviews, interviews with staff, observations of care and services, reviews of policies and procedures, it was determined that the facility failed to revise and implement the comprehensive person center care plan for one of five residents reviewed related to sexually inappropriate behavior. (Residents R139).

Inspectors wroteBased on review of facility policy, resident's clinical record, observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to razors and large accumulations of personal items which impaired mobility of residents around the room for three of 31 residents reviewed. (Resident R83, Resident R12 and Resident R5)

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed receiving hemo-dialysis (Resident R5).

Inspectors wroteBased on a review of the facility's nursing staff competencies and skills required to provide resident care, the facility failed to ensure complete competency documentation for four of the five nursing staff reviewed. (Employees E5, E7, E8, and E10) Findings Included: According to the facility policy titled Staffing, Sufficient and Competent Nursing, (revised August,2022) under the section Competent Staff, a competency is defined as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. A review of the facility policy Staffing, Sufficient and Competent Nursing confirmed that competencies are intended to measure the knowledge, skills, and abilities necessary for staff to perform their roles effectively. [...]

Inspectors wroteBased on a review of the facility assessment and staff interviews, the facility failed to ensure active involvement of direct care staff and input from residents, resident representatives, and family members in the development and revision of the facility assessment. Additionally, the facility failed to identify within the facility assessment a resident population with inappropriate sexual behaviors. The facility census was 154. Findings Included: Review of the facility's Facility Assessment revealed the most recent revision date was January 2026. The document did not indicate that direct care staff, residents, resident representatives, or family members were involved in the development or revision of the assessment. There was no documentation demonstrating that input from these individuals was obtained during the process. [...]

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of five residents reviewed with an indwelling suprapubic urinary catheter (Residents R13) and failed to disinfect a medical equipment on two of the three residents observed during medication administration (Resident R2, and Resident R3).

Inspectors wroteBased on review of clinical records, facility policy, and interview with staff, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization (Resident R1).

Inspectors wroteBased on observations in the main kitchen and staff interview it was determined that the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility did not ensure that that trash was properly disposed of in the receiving and dumpster area. Findings Include: A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. Observations in the receiving area outside revealed trash, food, and debris on the ground surrounding the dumpsters. On one dumpster, the lid was open, and trash was exposed. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa.

Inspectors wroteBased on observations, review of facility documentation, and staff interviews it was determined that the facility failed to establish an effective pest control program in the main kitchen. Findings Include: Review of pest control report dated March 4, 2025, revealed pest control inspected and treated the kitchen areas, storage areas, and dishwasher room for occasional invaders. Per the pest control report, mice droppings were observed in the kitchen food storage room. Pest control recommended a door sweep in the kitchen doors and replacing doors to the small room outside, next to the dumpster, as te doors are rotten. A tour of the main kitchen was conducted on March 17, 2025, at 9:22 a.m. with the Food Service Director, Employee E5. Observations revealed double doors adjacent to the main kitchen where food deliveries are accepted and lead out to where the dumpsters are stored. [...]

Inspectors wroteBased on a review of the facility policy, observations, and an interview with staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors and lobby (Second Floor, Third Floor, and Fourth Floor).

Inspectors wroteBased on observations, interviews with residents and staff, and review of the facility policy, it was determined that the facility failed to provide a clean, safe, comfortable and homelike environment in three of the three nursing units observed (2nd, 3rd, 4th floor Nursing Units).

Inspectors wroteBased on observations during dining and resident interviews it was determined that the facility failed to serve food that was palatable and attractive to meet resident needs for 20 of 20 residents reviewed (Resident R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93, R30, R9, R120, R122, R81, R108, R83, R58, and R139). Findings Include: During a Resident Council meeting on March 18, 2025, at 10:30 a.m. with 11 alert and oriented residents (R62, R13, R35, R129, R70, R49, R6, R4, R96, R92, R93) residents reported that the chicken being served is dry. Review of the facility menu revealed chicken was on the menu for lunch on March 18, 2025. Observations on March 18, 2025, at approximately 12:30 p.m. on the 2nd floor nursing unit during the lunch time meal revealed the following: Observations and interview at 12:38 p.m. [...]

Inspectors wroteBased on review of facility protocol, observations, interview ,and review of clinical records, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) for one resident on enhanced barrier precautions during morning care and wound observation of 31 resident records reviewed (Resident R102).

Inspectors wroteBased on a resident group interview, resident interview, review of facility policy and staff interview, it was determined that the facility failed to ensure that prompt efforts were made to resolve grievances for one of thirty-one residents (Resident R30) and effectively communicate the resolutions of grievances for 11 of thirty-one residents (R4, R6, R13, R35, R49, R62, R70, R92, R93, R96, R129)

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to identify the placement of beds against the wall as a restraint and failed to assess the functional status of an individual resident to determine the use of the restraint for one of 31 residents reviewed. (Residents R5). Findings Include: Review of facility policy titled Use of Restraints, revised 2017, revealed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e, side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. [...]

Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to perform Elder Abuse and Resident Rights training upon hire for one of five personnel files reviewed (Employee E4). Findings Include: Review of the personnel file for Cook, Employee E4 on March 20, 2025 at 12:02 pm revealed employee hire date on December 5, 2024. Further review indicated that there was no documented evidence for completion of Elder Abuse training upon hire. An interview was conducted with Business Office/ HR, Employee E5, on March 20, 2025 at 12:13 pm, confirmed Employee E4's Elder Abuse training incomplete. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

Inspectors wroteBased on clinical record review, it was determined that the facility failed to notify the representative of the Office of the State Long Term Care Ombudsman for one of 31 residents sampled who were transferred to the hospital. (Resident R102).

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was determined that the facility did not ensure revisions were made to the PASRR (Pre-admission Screening and Resident Review) application to include mental health diagnoses for 2 out of 2 residents reviewed. (Resident R71, R98)

Inspectors wroteBased on review of facility policy, facility documents, clinical records, and interview with staff, it was determined the facility failed to develop a comprehensive care plan and interventions to address resident care needs for Resident R37's diagnosis of diabetes, Resident R115 respiratory care, Resident R97 mood, R75 and R136 psychotropic medication, for five of 31 residents reviewed (Resident R37, R115, R136, R97, and R75).

Inspectors wroteBased on staff interviews, and review of resident records determined the facility failed to document to ensure one resident (Resident R102) received treatment and care in accordance with professional standards of practice when the facility failed to properly assess and document a change of condition per physician orders for one of 31 records reviewed. (Resident R102)

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interview it was determined that the facility failed to provide pressure ulcer treatment, consistent with professional standards of practice, for one of three residents reviewed for pressure ulcers (Resident R18). Findings Include: Review of facility policy Pressure Ulcers/Skin Breakdown revised April 2018 revealed the nurse should describe and document/report a full assessment of the pressure ulcer including location, stage, length, width, and depth. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. [...]

Inspectors wroteBased on a review of clinical records and facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for two of 31 residents reviewed. (Resident R115 and R63).

Inspectors wroteBased on observation interview with resident and staff and review of clinical records and facility policy it was determined that the facility failed to appropriately assess residents for use of bedrails and failed to ensure correct installation, use and maintenance of bed rails were maintained for two of 31 resident records reviewed (Resident R37 and R77).

Inspectors wroteThe facility failed to ensure that one resident, who displayed mental disorder or psychosocial adjustment difficulty, received treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of four residents reviewed for mood/behavior (Resident R97). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and diagnoses of non-Alzheimer's dementia and depression. Further review of Resident R97's MDS dated [DATE], revealed the resident scored a 17 under section D Mood which can be interpreted as moderately severe depression. [...]

Inspectors wroteBased on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed medication to meet the needs of one of 31 residents reviewed (Resident R16).

Inspectors wroteBased on observations and staff and resident interviews it was determined that the facility failed to provide a substitute for a resident who requested a meal alternative and failed to serve foods that accommodate a residents allergies for two of 26 residents reviewed during dining (Resident R97 and R6). Findings Include: Review of Resident R97's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 6, 2025, revealed the resident was admitted to the facility on [DATE], had moderate cognitive impairment, and had a diagnosis of malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients). Observations on March 17, 2025, revealed an always available menu dated February 18, 2025, posted on the wall on the 2nd floor nursing unit located next to the elevators. [...]

Inspectors wroteBased on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for five of 31 residents reviewed. (Resident R37, R115, R153, 109, R88 ).

Inspectors wroteBased on interviews with residents and staff, and review of temperature logs, it was determined that the facility failed ensure that essential mechanical equipment ws maintain in working function to provide comfortable bathing temperatures on two of three nursing floors. (Second and Fourth floor)

Inspectors wroteBased on a review of clinical records, facility policies, and interviews with staff and residents, it was determined that the facility failed to implement comprehensive, person-centered care plans for one out of the seven records reviewed (Resident R1).

Inspectors wroteBased on review of personnel files, facility documentation and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for three of three personnel files reviewed related to skills competencies evaluations (Employees E5).

Inspectors wroteBased on review of facility policy and procedures, review of clinical records, and staff interview, it was determined that the facility failed to allow a resident to return to the facility following a hospitalization for one of eight residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, Admissions Policies undated states, Policy Statement- Written policies and procedures governing admissions to the facility will be maintained on a current basis to ensure fair and impartial admission practices. The objectives of our admission policies are to: a. Provide uniform guidelines in the admission of residents to the facility; b. Admit residents who can be adequately care for by the facility; c. Reduce the fears and anxieties of the resident and family during the admission process; d. [...]

Inspectors wroteBased on facility policies, clinical record review and staff interviews, it was determined that the facility failed to communicate to the resident's physician assistant the refusal of a prophylactic anticoagulant medication for one of eight residents reviewed. This failure resulted in actual harm to Resident R86 who missed nine doses of an anticoagulant medication and development of Deep Venous Thrombosis. (Resident R86)

Inspectors wroteBased on observations, review of facility policy and staff and resident interviews, it was determined that the facility failed to maintain a clean and homelike environment in the main dining room and two of three nursing units (Second floor and Third Floor). Findings Include: Review of facility policy titled Bath, Shower, Tub revised February 2018 revealed the purpose of the procedures are to promote cleanliness, provide comfort to the resident and observe skin conditions. This policy included instructions including: to be sure the tub or shower is clean, the bath area is a comfortable temperature for the resident, if using a shower regulate the temp and the flow of the water warm water is 105 degrees Fahrenheit. [...]

Inspectors wroteBased on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted to rule out abuse/neglect for a bruise of an unknown original for 1 out of 30 residents reviewed (Resident R39)

Inspectors wroteBased on observations, review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized, comprehensive care plan with measurable objectives and interventions to meet the resident's needs for one of 30 residents reviewed (Resident R140). Findings Include: Review of Resident R140's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2024, revealed the resident had moderate cognitive impairment, and functional limitation in range of motion to upper and lower extremities. Further review of the MDS revealed Resident R140 had diagnoses of hemiplegia (one-sided paralysis or weakness), muscle weakness, and need for assistance with personal care. [...]

Inspectors wroteBased on observations, review of facility policy, staff interviews and the review of the clinical record, it was determined that the facility did not ensure that services provided met professional standards of practice in regard to a change in a resident's medical condition for 1 out of 30 residents reviewed (Resident R39).

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure interventions were implemented for the prevention of pressure ulcers for one of five residents reviewed for pressure ulcers (Resident R1). Findings Include: Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 25, 2024, revealed the resident was cognitively impaired and had diagnoses of diabetes mellitus (disorder of carbohydrate metabolism) and hemiplegia (one-sided paralysis or weakness). Review of Resident R1's comprehensive care plan revised on January 22, 2024, revealed the resident was at risk for developing wounds related to non-compliance with care. Intervention dated February 16, 2024, included to offload heels as ordered. [...]

Inspectors wroteBased on observations, staff interviews, and review of clinical records, it was determined that the facility failed to ensure that weekly weights were obtained for 2 out of 30 residents reviewed with a history of weight loss (Resident R39 and Resident R454).

Inspectors wroteBased on observation, staff interviews, review of clinical records and review of facility policy, it was determined that the facility failed to ensure that medications were delivered from pharmacy timely for two of 30 resident records reviewed (Resident R133 and Resident R39).

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was determined the facility failed to ensure that as needed psychotropic medication included an end date for stoping the medication for one of 30 resident records reviewed (Resident R25).

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure labs were completed per physician orders for one of 30 residents reviewed (Resident R118). Findings Include: Review of facility policy Lab and Diagnostic Test Results - Clinical Protocol revised November 2018 reveled the physician will identify, and order lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. Review of Resident R118's clinical record revealed a physician order dated January 23, 2024, ordered by Nurse Practitioner, Employee E19, for laboratory values to be drawn on January 24, 2024. [...]

Inspectors wroteBased on review of clinical records, observations, and staff interview, it was determined that the facility failed to ensure beverages were provided in accordance with resident needs for three of three residents with orders for thickened liquids observed (Resident R1, R140, and R34). Findings Include: Review of Resident R1's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 25, 2024, revealed the resident was cognitively impaired and had a diagnosis of dysphagia (difficulty swallowing). Review of Resident R1's clinical record revealed a physician diet order dated January 25, 2024, that indicated Resident R1 was ordered nectar thick fluids (liquids that have been altered to a thicker consistency than water - nectar thick liquids are similar to that of fruit nectar). [...]

Inspectors wroteBased on observations, staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate clinical records for 1 out of 30 residents (Resident R89).

Inspectors wroteBased on clinical record review, hospital record review, interviews with staff and review of policies and procedure, it was determined that the facility failed to ensure that a benzodiazepine medication was administered as ordered by the physician which resulted in actual harm to Resident R3, who experienced a tonic clonic seizure and was diagnosed with a closed head injury and left frontal scalp hematoma for one of four residents reviewed. (Resident R3)

Inspectors wroteBased on clinical record review, interviews with staff, hospital record reviews and reviews of policies and procedures, it was determined that the facility failed to ensure that the physician was notified of a refusal of a laxative mediation for one of four residents reviewed. (Resident R4)

Inspectors wroteBased on clinical record review reviews of policies and procedures and interviews with residents and staff, it was determined that the facility failed to address the behavioral health needs and services for one of two residents. (Resident R1)