A list of the most recent deficiencies for Majestic Care of Flushing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-14 | 2023-12-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-27 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-27 | 2023-06-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-27 | 2023-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-04 | 2023-06-02 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-04 | 2023-06-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-04 | 2023-06-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-04 | 2023-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-04 | 2023-06-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-04 | 2023-06-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-04 | 2023-06-02 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-04 | 2023-06-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-04 | 2023-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-04 | 2023-06-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-04 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-06-02 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-04 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-06-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Develop a communication plan. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-06-02 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-23 | 2022-07-26 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-02-23 | 2022-07-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-23 | 2022-07-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-23 | 2022-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-23 | 2022-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-23 | 2022-07-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-23 | 2022-07-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-23 | 2022-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-10 | 2022-07-26 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-03-07 | 2022-07-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-07 | 2022-07-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-21 | 2022-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-23 | 2022-05-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-23 | 2022-05-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-23 | 2022-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-23 | 2022-05-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-23 | 2022-05-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-23 | 2022-05-09 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-02-23 | 2022-05-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-23 | 2022-05-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide or obtain dental services for each resident. | Health | 2022-02-23 | 2022-05-09 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-02-23 | 2022-05-09 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-23 | 2022-05-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-02-23 | 2022-05-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-23 | 2022-05-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-23 | 2022-05-09 | N |
| Keep all essential equipment working safely. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2022-02-23 | 2022-05-09 | N |
| Provide appropriate foot care. | Health | 2022-02-23 | 2022-05-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-23 | 2022-05-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-10 | 2022-05-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-10 | 2022-05-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-10 | 2022-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-10 | 2022-05-09 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-10 | 2022-05-09 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-10 | 2022-05-09 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-03-07 | 2022-05-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-07 | 2022-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-07 | 2022-05-09 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-07 | 2022-05-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-07 | 2022-05-09 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-03-07 | 2022-05-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-07 | 2022-05-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-07 | 2022-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-05-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-07 | 2022-05-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-07 | 2022-05-09 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-07 | 2022-05-09 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-03-07 | 2022-05-09 | Y |
| Post nurse staffing information every day. | Health | 2022-03-07 | 2022-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-05-09 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-07 | 2022-05-09 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-09 | 2022-04-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-09 | 2022-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-09 | 2022-04-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-09 | 2022-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-30 | 2021-07-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-03 | 2021-07-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-03 | 2021-07-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-03 | 2021-07-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-03 | 2021-07-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-03 | 2021-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-07-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-03 | 2021-07-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-06-03 | 2021-07-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-07-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-12 | 2020-11-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-10-12 | 2020-11-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-10-12 | 2020-11-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-10-12 | 2020-11-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-12 | 2020-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-12 | 2020-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-12 | 2020-11-17 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-10-12 | 2020-11-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-10-09 | 2020-11-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-09 | 2020-11-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-09 | 2020-11-17 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-10-09 | 2020-11-17 | N |
