Majestic Oaks Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Majestic Oaks Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF580May 28, 2024

  Based 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) Findings include: Review of facility policy titled Documentation of Medication Administration dated October 20, 2023, revealed that A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). […]

• Actual harm, isolatedF684Apr 24, 2024

  Based 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) Findings include: Review of the facility policy and procedure titled Medication Administration dated April, 2007, revealed that it was the responsibility of the licensed professional to document all medications administered to each resident as prescribed by the physician. […]

• Actual harm, isolatedF600Aug 24, 2022

  Based on a review of clinical records, review of facility documentation, review of facility policy, and interviews with staff, it was determined that the facility failed to ensure residents were free from sexual abuse which resulted in actual harm to Residents R1 who was subjected to nonconsensual sexual activity by Resident R2 and R3 for three of five resident records reviewed (Resident R1, R2, and R3). Findings include: Review of facility policy Abuse and Neglect - Clinical Protocol, revised July 2017 revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF689Aug 24, 2022

  Based on the review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to ensure adequate supervision to Resident R2 and R3 which resulted in harm to Resident R1, who was subjected to nonconsensual sexual activity by Resident R2 and R3 for one of five resident records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was diagnosed with rhabdomyolysis (breakdown of skeletal muscle), dementia (impaired cognition), aphasia (difficulty to comprehend or formulate language), weakness and difficulty in walking. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  Based 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. Findings include: A tour of the Food Service Department conducted on March 17, 2025, at 9:22 a.m. with Employee E5, Food Service Director, revealed the following concerns: Observations of the walk-in freezer revealed two tortillas loosely wrapped in plastic wrap with no dates. Observations of the dry storage room revealed the juices used for the juice machine were stored in this room. […]