Inspection Reports for
Majestic Care Center

The facility failed to ensure that a PASARR Level I screening was accurately completed for one of four residents reviewed, as the screening did not reflect the resident's documented diagnoses of major depressive disorder and bipolar disorder.

The facility failed to provide timely BiPap respiratory care for a resident, served food that was not palatable or at safe temperatures to multiple residents, and did not maintain proper sanitation and chemical sanitizer levels in the kitchen, including failure to discard expired food items.

Complaint NJ163766 related to failure to provide emergency tracheostomy equipment and staff training for Resident #313. Complaint NJ169862 related to pharmaceutical services including controlled medication accountability, insulin pen storage, and medication administration timeliness.

The facility failed to ensure emergency tracheostomy equipment was available and staff were trained to use it, resulting in immediate jeopardy to resident health. Additionally, the facility failed to maintain proper documentation and timely administration of respiratory medications, failed to maintain accountability for controlled medications in the automated dispensing system, and improperly stored insulin pens without infection control measures.

The complaint investigation included issues related to failure to issue Medicare beneficiary notices, staff credential verification, medication administration errors, respiratory care deficiencies including emergency tracheostomy equipment and training, dietary assessment delays, and pharmaceutical service failures including controlled medication accountability and insulin pen storage.

The facility was found deficient in issuing required Medicare beneficiary notices timely, verifying staff credentials and references, developing comprehensive care plans, administering medications according to physician orders and professional standards, ensuring emergency respiratory equipment and staff training for tracheostomy care, conducting timely dietary assessments, maintaining accountability for controlled medications, and proper storage of insulin pens. Several medication administration delays and documentation issues were also identified.

Complaint investigation included multiple NJ complaint numbers: 163766, 165891, 167106, 168173, 168717, 169228, 169862, 169297, 171864, 171947, and 173833. The Immediate Jeopardy was identified during this complaint-related survey.

The facility was found to be in noncompliance with several regulatory requirements including an Immediate Jeopardy (IJ) situation related to emergency equipment availability and staff training for Resident #313, deficiencies in Medicaid/Medicare coverage notices, abuse/neglect policies, comprehensive care plans, medication administration, nursing staff credential verification, life safety code violations including fire safety and sprinkler system maintenance, and medication dispensing system discrepancies. Corrective actions and re-education plans were implemented with completion dates mostly by 10/20/2024.

Complaint #: NJ 00176554. The complaint investigation found the facility deficient in staffing ratios but no residents were affected. The facility must submit a plan of correction and ensure implementation to avoid enforcement action.

The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on 3 of 14-day shifts. No residents were affected by the deficient practice, and a plan of correction was submitted.

Complaint #165731 involved failure to maintain safe indoor temperatures during a heat emergency caused by malfunctioning air conditioning systems on the 2nd and 3rd floors, resulting in immediate jeopardy to resident health and safety. The complaint included failure to identify high-risk residents, failure to implement adequate cooling measures, failure to monitor room temperatures, and failure to activate emergency response plans. One resident was hospitalized due to heat-related illness.

The facility failed to maintain adequate room temperatures, identify high-risk residents, implement cooling measures, monitor room temperatures, and activate the emergency response plan timely during a heat emergency. Several residents experienced excessive heat exposure, with one resident hospitalized due to heat-related symptoms. The medication storage room was also found to be above recommended temperatures. The facility administration failed to effectively manage the emergency, including delayed notification to authorities and lack of temperature logs.

Complaint #165731 regarding malfunctioning air conditioning and heat emergency conditions leading to resident harm and regulatory noncompliance.

The facility failed to maintain adequate room temperatures during a heat emergency, did not properly monitor or document temperatures, failed to notify the Department of Health timely, and did not adequately protect residents at risk, resulting in an immediate jeopardy situation. Resident #1 was hospitalized due to heat-related illness. The facility also failed to maintain properly stocked emergency code carts and had expired emergency equipment.

The facility was found to have multiple deficiencies including emergency lighting failures, fire-rated door issues, hazardous area door closures, sprinkler system installation problems, portable fire extinguisher inspection lapses, ventilation system failures in resident bathrooms, missing GFCI protection on electrical outlets near water sources, and lack of a remote emergency stop button for the emergency generator.

Complaint Intake NJ144796 and others; substantiation status not explicitly stated.

The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for 15 of 42 shifts reviewed, potentially affecting all residents. The Director of Nursing stated staffing was based on resident acuity and that the facility met staffing ratios, despite documented deficiencies.

Deficiencies were cited related to failure to complete required Minimum Data Set (MDS) discharge assessments for 5 of 6 residents reviewed, and failure to ensure proper positioning and accurate administration of enteral feeding for one resident, which posed risks for complications.

The facility was found not in substantial compliance with the Life Safety Code due to failure to annually inspect and test the piped-in medical gas system since April 30, 2018, and failure to properly secure compressed gas cylinders to prevent tipping and rupture.