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
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! 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 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 R103 was non-verbal with no open wound ongoing during her assessment.
Although 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 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, 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 .
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Care of Flushing
540 Sunnyside Drive Flushing, MI 48433
SUMMARY STATEMENT OF DEFICIENCIES
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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