Majestic Care Of Flushing
Majestic Care of Flushing in Flushing, MI — inspection on August 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
back in bed, and there were no other skin impairments noted on the legs, ankles, and feet during the
Progress Notes dated August 7, 1925, which stated that at 5:15 PM, I received a text regarding a
wound culture. Dr. K was not sure what happened, but the following day on 8/8/25, 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 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 .
235132 08/22/2025
Majestic Care of Flushing 540 Sunnyside Drive Flushing, MI 48433
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.