Majestic Care of Kent: Missed Insulin Doses - OH
The resident, identified in inspection records only as Resident 61, had been admitted to the 55-bed facility just two days earlier, on December 21, 2024. His diagnoses included diabetes mellitus, hypertension, and heart failure — a combination that makes blood sugar control not a matter of comfort but of medical urgency.
His physician had ordered two insulin regimens starting December 22, the day after admission. The first was Insulin Lispro, 55 units to be given every morning and every night. The second was Humalog sliding scale insulin, a dose calibrated to his actual blood sugar readings, to be given four times daily: morning, lunch, dinner, and bedtime.
On December 23, neither the morning Lispro nor the lunchtime Humalog was administered.
The medication administration record for December 2024 shows both gaps plainly. His care plan, updated that same day, December 23, noted that he had diabetes and that staff should administer his medications as ordered. The order was in the chart. The care plan flagged it. The doses still did not happen.
The Director of Nursing Services confirmed the missed doses in an interview with inspectors on August 28, 2025 — more than eight months after the incident. There was no dispute about what the record showed.
The inspection, which examined medication administration for six residents, found the problem in one of them. That resident was Resident 61.
Inspectors classified the violation under F0755, which covers pharmaceutical services, and rated the level of harm as minimal harm or potential for actual harm. The finding was tied to two separate complaints, numbered 1364233 and 1364234, filed against the facility.
What the rating does not capture is the clinical reality of what a missed insulin dose means for a patient managing diabetes alongside heart failure and hypertension. Uncontrolled blood sugar strains the cardiovascular system. For someone whose heart is already compromised, the margin for error is narrow. A 55-unit morning dose of Insulin Lispro is not a small prescription. It is a substantial, physician-ordered intervention, set at that level for a reason.
The sliding scale Humalog missed at lunch compounds the picture. Sliding scale insulin exists precisely because blood sugar fluctuates. It is meant to catch and correct elevations that a fixed dose alone cannot anticipate. Skipping it means whatever his glucose was at noon on December 23 went uncorrected until dinner.
The facility's own medication administration policy, dated January 2, 2024, states that medications are to be administered as ordered. The policy existed. The physician's orders existed. The care plan existed. None of it produced the doses on December 23.
Resident 61 had been a patient at Majestic Care of Kent for exactly two days when the lapses occurred. He had come in with a documented history of diabetes. His insulin orders were written the day after admission. The expectation that those orders would be followed from the first full day forward was not a complex one.
The Director of Nursing, in confirming the record, offered no account of why the doses were missed or what, if anything, the facility did in response at the time. The inspection report does not indicate that any internal incident report was filed, that the physician was notified, or that Resident 61's blood sugar was monitored with any additional frequency that day to compensate for the gap.
What the record shows is a man, newly admitted, with serious diagnoses, whose insulin was not given twice in a single day, and whose facility acknowledged it only when asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Kent from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
MAJESTIC CARE OF KENT in KENT, OH was cited for violations during a health inspection on September 10, 2025.
The resident, identified in inspection records only as Resident 61, had been admitted to the 55-bed facility just two days earlier, on December 21, 2024.
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.