Majestic Care of Flushing: Wound Care Failures Cause Harm - MI
That admission, recorded by federal inspectors during an August 2025 complaint investigation, sits at the center of a deficiency rated as causing actual harm to the resident, identified in records as R103.
The therapist told inspectors she had been working with R103 when she noticed the wound on the inner side of his left heel. It was rounded, slightly raised, and superficial. She said she immediately notified the Rehab Department Director and the Director of Nursing. She could not say what day she found it. It was not in the notes. She said R103 doesn't move much, and she had not seen any repetitive or jerky movements in his feet during their session. He had not expressed pain. She had no explanation for how the wound developed.
R103 is non-verbal and bedbound.
The facility's physician, Dr. K, told inspectors she saw R103 a few days after his admission. On June 25, 2025, she examined him and noted no open wounds, no skin impairments on his legs, ankles, or feet. She said she examined his back while he was in bed. Nothing alarming.
Her next documented encounter with R103 came on August 7, 2025, when she received a text message about a necrotic coccyx with foul drainage. More than six weeks had passed since her last assessment. The wound on his tailbone had progressed to the point of tissue death and infection. She ordered Bactrim immediately following a wound culture.
The following day, R103 was started on Clindamycin instead. Dr. K told inspectors she had ordered Bactrim, not Clindamycin. She was not sure what happened. The resident was discharged on August 8, 2025, and she did not follow up.
A third physician, Dr. L, was unreachable during the investigation, described as being on an international vacation. Inspectors noted that R103's electronic medical record contained seven late-entry progress notes. Dr. J and Dr. K both told inspectors that dictated notes should not take more than 48 hours to appear in the record. Neither physician was aware that all seven of R103's notes had been delayed.
Seven late entries. Neither doctor knew.
The inspection report does not say how long R103 had been at the facility before the heel wound was found, or how long the coccyx wound had been developing before it reached the stage of necrosis and foul drainage. It does not say whether anyone at the facility connected the heel wound found during therapy to the deteriorating condition of his tailbone. The record does not show those dots being connected.
What it shows is a non-verbal man who could not report his own pain, tended by staff who acknowledged they did not know how his wounds developed, overseen by a physician who went from noting clean skin in late June to receiving a text about rotting tissue in early August, and whose antibiotic order was not followed on his final day in the building.
The facility's wound management policy, reviewed by inspectors on the day of the survey, states that wound treatments will be provided in accordance with physician orders and that licensed nurses will notify physicians to obtain treatment orders when none exist. The policy was dated January 2024.
R103 was discharged on August 8. Whether his wounds were healing or worsening when he left, the inspection report does not say.
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 therapist told inspectors she had been working with R103 when she noticed the wound on the inner side of his left heel.
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.