Majestic Care of Flushing: Wound Care Failures - MI
The inspection at Majestic Care of Flushing, completed August 22, 2025, found that the resident, identified as R103, had no documented skin problems on her legs, ankles, or feet as of a June 25 examination. By August 7, that had changed. At 5:15 in the afternoon, her physician, Dr. K, received a text about a necrotic coccyx wound with foul drainage. She ordered Bactrim, to be given immediately after a wound culture.
The next morning, R103 was started on Clindamycin instead.
Dr. K told inspectors she was not sure what happened. R103 was discharged on August 8, 2025, and Dr. K did not follow up on the medication discrepancy or the wound's outcome.
The inspection also found that seven progress notes for R103 had been entered late into the electronic medical record. The attending physician, Dr. L, was unreachable during the investigation, on an international vacation. Two other physicians, Dr. J and Dr. K, told inspectors that dictated notes should not take more than 48 hours to enter. Both said they were unaware the seven entries had been delayed at all.
CMS rated the harm as actual, not potential.
The facility's own wound management policy, dated January 2024, states that treatments will be provided in accordance with physician orders, including the type of dressing, cleansing method, and frequency of change. It also states that when treatment orders are absent, a licensed nurse will notify the physician to obtain them.
What the policy does not account for is a physician's order being ignored entirely, a substitute drug given in its place, and the patient gone before anyone with knowledge of the original order could ask why.
Dr. K said she was not sure what happened. The record does not show that anyone else found out.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
Majestic Care of Flushing in Flushing, MI was cited for violations during a health inspection on August 22, 2025.
At 5:15 in the afternoon, her physician, Dr.
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.