Majestic Care Of Flushing

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was rounded in shape, a bit bigger, and superficial. The wound was located on the inner side of the heel of

the left foot. I immediately notified my Rehab Department Director and got the Director of Nursing. I don't remember what day it was, as it was not found in the notes. I don't know how the wound developed. I have no idea, to be honest! Resident R103 doesn't move very much. I did not observe any repetitive or jerky movements in his feet during the therapy session. He did not express any discomfort or pain.An interview with Dr. K was conducted by phone on 8/27/25 at 4:45 PM. She indicated that she does rounds to see residents and see them, but did not remember rounding with the wound nurse on a weekly or monthly basis. She further specified: We see patients individually. Dr. K reviewed Resident R103's medical record during the interview and stated that she saw the resident a few days after admission. On 6/25/25, Dr. K noted during examination that Resident R103 was non-verbal with no open wound ongoing during her assessment. Although Resident R103 was bedbound, Dr. K recalled examining his back in bed, and there were no other skin impairments noted on

the legs, ankles, and feet during the examination on June 25, 2025. The subsequent encounter I had with Resident R103 was pointed out in the Progress Notes dated August 7, 1925, which stated that at 5:15 PM, I received

a text regarding a necrotic coccyx with foul drainage. I ordered an antibiotic of Bactrim to give immediately

after a wound culture. Dr. K was not sure what happened, but the following day on 8/8/25, Resident R103 started on Clindamycin and not the Bactrim she had ordered. The resident was discharged on August 8, 2025, so she did not follow up.Late Entries progress notes entered Dr. L was unavailable for interview due to a scheduled vacation internationally, but according to both Dr. J and Dr. K, the dictated notes should not take more than 48 hours. The two physicians were unaware of the delay of all seven (7) Late Entries of progress notes in

the EMR for Resident R103.POLICIESOn August 22, 2025, at 3:30 PM, the Wound Management Policy was reviewed.Wound Management Policy (Original date-1/2/2024) Policy: To promote wound healing of various types of wounds. It is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Procedure:Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse .

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Care of Flushing

540 Sunnyside Drive Flushing, MI 48433

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Manager I was interviewed on 8/21/25 at 5:00 PM and recalled that Nurse G came to his office to fax the refill order of Oxycodone. I helped him faxed it over but Nurse G never told me that Resident R108 was out of the medication. Nurse G did not notify me that Resident R108 was administered her last dose at 11:00 AM. We have them in Backup. The back up pharmacy was here yesterday and was filling the back-up meds. Oxycodone are available in the back up box. Nurse Manager N was interviewed on 8/21/25 at 5:15 PM. She recalled that on 8/20/25, the Oxycodone order was changed from a PRN (as needed to around the clock every 6 hours. She obtained the order from the doctor and got an order. Nurse Manager N admitted that she was not aware that Resident R108 was out of the Oxycodone. Nurse G never told her. I just found out now. Nurse G did not check the backup box. Oxycodone is available in EDK. Although there is a process to obtain the narcotic, I can easily help if I was told. Resident R108 missed at least 4 doses. Nurse Manager N reported that the last dose of the ordered oxycodone 5 mg every 6 hours was on: 8/20/25 at 1400 (2:00 PM) Oxycodone/APAP 5 mg 1 tablet 8/20/25 at 5:30 PM Tylenol was givenShe stated Then there were 4 missed doses in over 24 hours. We just administered now from the back-up on 8/21/25 at 5:00 PM so that's over 24 hours. We will be on it now and we have educated the nurse about the refill and process of the EDK. On 8/21/25 at 5:30 PM, a follow-up interview Resident R108 reported her pain is now at 6 to 7/10 and had received oxycodone as ordered. According to the Director of Nursing (DON) on 8/22/25 at 2:42 PM, according to her investigation last oxycodone was administered on 8/20/25 at 2:00 pm then at around on the same day, the nurse gave her Tylenol.The pharmacy delivered her medicine on 8/22/25 and her oxycodone was given at 7/22/25.There was no oxycodone dose given from 8/20 at 2 pm until 8/22 when it arrived aand administered at 7:30 am. An interview with Dr. K was conducted by phone on 8/27/25 at 4:45 PM. She stated that that was not acceptable to have a resident wait and not have pain relief. Dr. K indicated that the greatest adverse effect to monitor for this case is the opioid withdrawal. She stated I recall signing the order form that night so it will be sent it to the pharmacy right away. I was unaware of any discrepancy. They did not notify me of any missed doses. A list of available medication in the Narcotic Emergency Drug Kit (Emergency Back-up Box) (undated) was reviewed and revealed three types of oxycodone were available at the facility. A list of Oxycodone Narcotic Medication were available:Oxycodone /APAP 5 mg -325 TabOxycodone/APAP 10 mg-325 TabOxycodone/APAP 7.5mg-325 Tab A list of other available narcotics in

the back-up box were:Hydrocodone/APAP 5 mg-325 TabHydrocodone/APAP 10 mg-325 TabHydrocodone/APAP 7.5-325 mg Tab The following facility policies were reviewed on 8/22/25 at 3:45 PM:Policy #1: Pain Management Policy (dated 1/2/2024) Policy- The facility must ensure that pain management is provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences.

Procedure- The Facility will utilize a systemic approach for recognition, assessment, treatment and monitoring pain.2. Policy #2 Controlled Substance Orders (review date 1/27/2025) Policy- To define the process for ordering and dispensing controlled substance medication(s) in a manner in accordance with State and Federal regulations.3. Policy #3 Narcotic Emergency Drug Kit Usage- Manual Kit (EDK) (review date 1/27/2025) Policy: To ensure that EDK devices containing control substances are utilized in a manner compliant with state and federal regulations. Procedure: 1. Opening the EDK., 2. Reordering EDK unit Control Substance Stock., 3. Provider Order and Control Substance EDK Units., 4. Delivery and Exchange of Control EDK boxes.

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