Majestic Care of Flushing: Pain Medication Gap - MI
The resident, identified in inspection records as R108, had been prescribed oxycodone 5 mg every six hours for pain. The order had just been changed, on August 20, from as-needed to around-the-clock, a shift that signals worsening or persistent pain requiring consistent management. Her last dose under that schedule was administered at 2:00 PM that day. After that, nothing. A nurse gave her Tylenol at 5:30 PM.
Four doses came and went. Then a fifth. Then a sixth.
The nurse responsible, identified as Nurse G, had faxed a refill order to the pharmacy. She went to a manager's office to send the fax. She did not mention, at any point, that R108 had already taken her last pill. She did not check the facility's Narcotic Emergency Drug Kit, a locked backup supply stocked specifically for situations like this one. She did not call the doctor. She did not tell the nurse manager. She sent the fax and waited.
Manager I told inspectors he had helped Nurse G send the fax but had no idea R108 was out of medication. "Nurse G never told me that R108 was administered her last dose at 11:00 AM," he said. He noted the backup supply was right there. "Oxycodone is available in the backup box."
Nurse Manager N learned what had happened the same way the inspectors did — during an interview on the evening of August 21. "I just found out now," she told them. She confirmed that Nurse G had not checked the emergency kit and had not told anyone the resident was without medication. "Although there is a process to obtain the narcotic," Nurse Manager N said, "I can easily help if I was told."
By the time someone finally retrieved oxycodone from the backup supply, it was 5:00 PM on August 21. Over 24 hours had passed since R108's last dose.
That still wasn't the end of it. The Director of Nursing, interviewed the following day, told inspectors the pharmacy didn't deliver the refill until August 22, and the next documented dose wasn't given until 7:30 AM that morning. The gap from last dose to resumed medication was more than 40 hours.
When inspectors spoke with R108 on the evening of August 21, after she had finally received a dose from the backup kit, she rated her pain at 6 to 7 out of 10.
Dr. K, the prescribing physician, was reached by phone on August 27. She said she had signed the order the night it was changed, expecting it to be sent to the pharmacy immediately. Nobody had told her anything had gone wrong. "That was not acceptable to have a resident wait and not have pain relief," she said. She identified the most serious risk from the delay: opioid withdrawal. A patient switched to scheduled, around-the-clock opioid dosing is receiving that level of medication because their system has come to depend on it. Abrupt gaps don't just mean unmanaged pain. They can mean withdrawal.
The inspection record lists the emergency drug kit as containing oxycodone/APAP in three different strengths: 5 mg, 7.5 mg, and 10 mg. Hydrocodone combinations were also available. The kit existed precisely so that a situation like this one would never require a resident to wait.
The facility reviewed its own policies with inspectors on August 22, pulling out its Pain Management Policy, its Controlled Substance Orders policy, and its Narcotic Emergency Drug Kit Usage policy. All three were on file. The EDK policy included step-by-step procedures for opening the kit, reordering stock, and obtaining a provider order for its use.
Nurse Manager N told inspectors the facility had educated Nurse G about the refill process and the emergency kit after the fact. "We will be on it now," she said.
R108's pain score, when inspectors last spoke with her, was still a 6 or 7 out of 10.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Flushing from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
Majestic Care of Flushing in Flushing, MI was cited for violations during a health inspection on August 22, 2025.
The resident, identified in inspection records as R108, had been prescribed oxycodone 5 mg every six hours for pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.