Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Center For Rehab & Sub-acute Care during CMS and state inspections, most recent first.
A facility failed to complete an accurate PASARR Level I for a newly admitted resident. The screening marked no mental illness diagnoses, even though the admission summary, MDS, and psych note all documented bipolar disorder, and the admission summary also listed major depressive disorder. The SW stated PASARRs were created on admission if missing and redone if a resident had a psych crisis, hospital transfer, or new psych dx.
A facility failed to provide necessary emergency tracheostomy equipment and ensure staff were trained for a resident with a tracheostomy, leading to hospital transfers. The resident was admitted without proper supplies, and staff were unprepared to handle tracheostomy emergencies. Additionally, the facility did not consistently document respiratory treatments or clarify physician orders, contributing to inadequate care.
The facility failed to maintain accountability for controlled medications, with discrepancies in the automated dispensing system and lack of a comprehensive policy. Insulin pens were improperly stored, increasing infection risk, and Labetalol HCL was administered late to a resident without proper documentation or physician notification, indicating deficiencies in medication management and infection control.
A resident did not receive the required SNF ABN and NOMNC forms in a timely manner, with the NOMNC signed after the last covered day of Medicare Part A service. The facility lacked a specific policy for these notifications, and the forms were not signed prior to the last covered date, as confirmed by the DSS and RDON.
The facility failed to verify the credentials of licensed staff and conduct reference checks for several employees, as required by its abuse policy. This deficiency was identified in the files of an LPN, an OT, and other staff members, with missing documentation of license verification and reference checks. The HRD and RDON confirmed these oversights during interviews.
A facility failed to develop a comprehensive person-centered care plan for a resident with multiple diagnoses, including an open wound, diabetes, and mental health disorders. The EMR review showed no completed care plan, which was confirmed by the UM. The facility's interdisciplinary care planning protocol was not adhered to, leading to this deficiency.
An LPN in an LTC facility failed to provide proper instructions for using a steroidal inhaler, allowing a resident to swallow water instead of rinsing and spitting, risking oral thrush. Additionally, the LPN administered Acetaminophen for a pain level higher than prescribed without consulting a physician. The resident had a history of pain and anxiety disorders and was cognitively intact.
A facility failed to conduct timely dietary assessments for a resident with a feeding tube who experienced weight loss. The resident, with a history of cerebral infarction and dysphagia, was observed with a non-operational feeding pump. The dietician, working part-time, did not complete necessary assessments due to time constraints, and there was no follow-up on the resident's weight loss. Interviews revealed a lack of clarity on the dietician's responsibilities, and the facility could not provide a policy on required documentation.
The facility failed to verify the certifications of two newly hired CNAs before employment, as required by policy. The Human Resource Director confirmed the absence of certification verification in the employment files of these CNAs, which is a breach of the facility's screening procedures.
Inaccurate PASARR Screening for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a PASARR Level I screening was completed accurately for a newly admitted resident. The resident’s PASARR screening, completed on entry to the facility, marked Section II for mental illness diagnoses as “No,” indicating no mental illness diagnoses were identified. However, the resident’s admission summary listed diagnoses including major depressive disorder and bipolar disorder. Record review also showed the resident’s MDS dated 11/30/25 documented a BIMS score of 15 out of 15, indicating the resident was cognitively intact, and Section I of the MDS listed bipolar disorder as an active diagnosis. The resident’s most recent psychiatric note, dated 12/3/25, also included bipolar disorder under diagnoses and plan. During interview, the SW stated that if a resident came into the facility without a PASARR she would create one, and that if a resident went to crisis or a hospital for a psychiatric issue, or developed a new psychiatric diagnosis, the PASARR Level I would have to be redone.
Failure to Provide Tracheostomy Care and Equipment
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy equipment and ensure staff were trained to use it for a resident with a tracheostomy. The resident was admitted without proper tracheostomy supplies, including an inner cannula, ambu bag, and an extra trach. This lack of supplies led to the resident being sent to the hospital on two occasions due to the absence of necessary equipment for tracheostomy care. Interviews with staff revealed that they were not adequately trained or prepared to care for a resident with a tracheostomy, and the facility did not have the required supplies at the bedside or within the facility. The resident, who had a history of acute respiratory failure with hypoxia, asthma, cocaine abuse, alcohol dependence, and homelessness, was admitted with a tracheostomy. Despite the resident's complex medical needs, the facility did not have the appropriate tracheostomy supplies available, and staff were not trained to handle tracheostomy emergencies. The pulmonologist and other staff members confirmed the absence of necessary equipment and the lack of training, which placed the resident at risk for serious harm. Additionally, the facility failed to consistently document in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) that oxygen and respiratory-related treatments were administered as ordered. There were also issues with clarifying physician orders and ensuring they were accurately transcribed and followed. The lack of documentation and incomplete physician orders further contributed to the inadequate care provided to the resident.
Removal Plan
- The DON conducted a house wide audit to resident physician orders and identified no additional residents with a trach were at the facility.
- The Assistant DON (ADON) completed education and in-servicing for all licensed staff on the location of trach supplies at the bedside and in the facility and to communicate the need for additional supplies on trach care and on trach care emergencies.
- The Pulmonologist was re-educated to inform the DON for trach supply related concerns should they arise in the future.
Deficiencies in Medication Management and Infection Control
Penalty
Summary
The facility failed to maintain a system of accountability for controlled medications, as evidenced by discrepancies in the automated medication dispensing system. During an inspection, the Director of Nursing (DON) and a Licensed Practical Nurse/Infection Preventionist (LPN/IP) identified a discrepancy in the count of Roxicodone tablets, which was not reported or resolved according to policy. The facility lacked a comprehensive policy for the automated medication dispensing system, and the DON was unable to provide documentation of shift-to-shift accountability, indicating a failure to ensure accurate counts and prevent potential diversion of controlled substances. Insulin pens were not stored in a safe and sanitary manner, as observed during the inspection of medication carts. Insulin pens belonging to multiple residents were stored together without being placed in individual bags, increasing the risk of infection. Staff members were unsure of the facility's policy regarding insulin pen storage, and the Consultant Pharmacist had not addressed this issue during inspections. The lack of a clear policy and proper storage practices for insulin pens contributed to the deficiency in infection control. The facility also failed to administer Labetalol HCL, a medication for high blood pressure, in a timely manner for a resident. The Medication Administration Record (MAR) indicated that the medication was frequently administered late, and there was no documentation of physician notification or rationale for the delays. The facility's policy allowed for a one-hour window for medication administration, but the repeated late administration of Labetalol HCL was not addressed, highlighting a deficiency in medication management and adherence to professional standards of nursing practice.
Failure to Provide Timely Beneficiary Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from a Medicare Part A stay. The resident did not sign the SNF ABN form, and the NOMNC was signed after the last covered day of Medicare Part A service. The Director of Social Services (DSS) acknowledged that both forms should have been signed prior to the last covered date and that the previous social worker made a mistake by not ensuring the forms were signed in a timely manner. The DSS also noted that the facility did not have a specific policy for these notifications and was following CMS guidance. The Regional Director of Nursing (RDON) and the Regional Licensed Nursing Home Administrator (Regional LNHA) confirmed that the forms should have been signed before the last covered date. They also acknowledged the lack of documentation indicating that the resident was notified in a timely manner. The RDON stated that the facility did not have a policy related to SNF ABN and NOMNC, and there was no evidence that the resident was informed before the last covered date. The Social Services job description emphasized maintaining appropriate documentation, which was not adhered to in this case.
Failure to Verify Staff Credentials and Conduct Reference Checks
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by the lack of verification of licensed staff credentials and incomplete reference checks for several employees. Specifically, the files of a Licensed Practical Nurse (LPN) and an Occupational Therapist (OT) did not contain documented evidence of license verification. Additionally, reference checks were missing for six employees, including LPNs, a Registered Nurse (RN), a Certified Nurse Aide (CNA), and the OT. This oversight was confirmed during interviews with the Human Resource Director (HRD) and the Regional Director of Nursing (RDON), who acknowledged that these checks should have been completed and documented in the employee files. The facility's policy on Residents/Patient Rights - Abuse, Neglect, Mistreatment, or Misappropriation of Resident/Patient's Property mandates thorough screening procedures, including reference checks, prior to employment. However, the facility did not adhere to these procedures, as evidenced by the missing documentation in the employee files. The HRD admitted to not verifying the active status of the LPN's license and acknowledged the absence of reference checks, which should have been conducted pre-employment. This deficiency was identified during a review of 10 employee files, with 8 files showing incomplete documentation.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for one resident, identified as Resident #26. This deficiency was identified through observation, interview, and review of facility documents. Resident #26 had multiple diagnoses, including an open wound on the left foot, non-pressure chronic ulcer, acute osteomyelitis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anxiety Disorder, Major Depressive Disorder, and Post Traumatic Stress Disorder. Upon reviewing the Electronic Medical Record (EMR), it was found that the Comprehensive Care Plan for this resident was not completed. During an interview, the Unit Manager confirmed the absence of the care plan and acknowledged that it should have been completed to guide staff in assisting the resident effectively. The facility's policy on interdisciplinary care planning outlines the roles of various departments in developing care plans, but this protocol was not followed in this case.
Failure to Administer Medications According to Physician Orders and Standards
Penalty
Summary
The facility failed to administer medications in accordance with physician's orders and professional standards of nursing clinical practice. During a medication pass observation, an LPN administered a steroidal inhaler to a resident without providing instructions to rinse and spit after use, which is necessary to prevent oral thrush. Instead, the resident was allowed to swallow water after taking oral medications, which does not substitute for proper rinsing and spitting as required for steroidal inhalers. Additionally, the LPN administered Acetaminophen 650 mg to the resident for a pain level of six out of ten, despite the medication being prescribed for mild pain levels of one to four. The LPN did not check for alternative pain management orders or consult with a physician before administering the medication, which was not in accordance with the resident's pain management plan. The resident involved was admitted with diagnoses including pain, opioid use, and anxiety disorder, and was fully cognitively intact with a BIMS score of 15 out of 15. The facility's policy requires that medications be administered according to physician orders, and PRN medications should be given as ordered and documented appropriately. The failure to follow these protocols was confirmed through interviews with the LPN, the LPN/Unit Manager, the Consultant Pharmacist, and the Director of Nursing.
Failure to Conduct Timely Dietary Assessments for Tube-Fed Resident
Penalty
Summary
The facility failed to conduct timely dietary assessments for a resident with a feeding tube who experienced weight loss. The resident, who had a history of cerebral infarction, dysphagia, and schizophrenia, was observed with a non-operational tube feeding pump. Despite having a care plan that included tube feeding and water flushes, the resident's nutritional assessments were not completed as required, leading to a lack of follow-up on the resident's nutritional status. The dietician, who worked part-time at the facility, admitted to not completing the necessary nutritional assessments due to time constraints and a high workload. The dietician acknowledged that a quarterly assessment was due but was not performed, and there was no documentation of follow-up on the resident's weight loss. The dietician also reported the issue to the Licensed Nursing Home Administrator, who maintained that the position was only for 24 hours per week. Interviews with the Director of Nursing and the MDS Coordinator revealed a lack of clarity regarding the dietician's responsibilities for completing quarterly assessments. The facility was unable to provide a policy outlining the dietician's documentation requirements. The job description for the dietician indicated that assessments should be conducted at least quarterly, but this was not adhered to, resulting in the deficiency.
Failure to Verify CNA Certifications
Penalty
Summary
The facility failed to ensure that all certified nursing staff hired had certifications in good standing, affecting two of ten newly hired CNAs. During a review of employee files, it was found that Employee #3, hired on 9/19/24, and Employee #8, hired on 7/6/23, did not have evidence of certification verification prior to employment. The Human Resource Director confirmed that the employment files for these employees lacked the necessary verification documentation. The facility's policy requires screening of all employees prior to employment, including verification through the State Nurse Aide Registry, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Camden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abigail House For Nursing & Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At Collingswood | 2.4 mi | ★★★★★ | 4 | 0 |
| St Monica Center For Rehabilitation & Healthcare | 2.4 mi | ★★★★★ | 0 | 0 |
| River Front Rehabilitation And Healthcare Center | 2.6 mi | ★★★★★ | 23 | 0 |
| Tucker House Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.