Inspection visit
Inspection
Citations
28 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
F584 - Safe Environment
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.
F585 - Grievances
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.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F742 - Based on the comprehensive assessment of a resident, the facility must
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the March 20, 2025 survey of MAJESTIC OAKS REHABILITATION AND NURSING CENTER?
This was a inspection survey of MAJESTIC OAKS REHABILITATION AND NURSING CENTER on March 20, 2025. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MAJESTIC OAKS REHABILITATION AND NURSING CENTER on March 20, 2025?
Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.