Majestic Mountain Care: Incomplete X-Ray Results - CA
The July 25 accident at Majestic Mountain Care Center left the resident with pain radiating down his spine into both arms. But for weeks afterward, the facility failed to obtain complete x-ray results that could have determined whether he sustained new injuries.
The nursing assistant was wheeling the resident outside for a smoke break when the incident occurred. According to the facility's root cause analysis completed three days later, the assistant was "pulling the resident's chair backwards" to get over the doorway threshold. The wheelchair was reclined to the resident's preference when it "tilted back and resident fell backwards."
The resident told inspectors during an August 26 phone interview that his pain had become intolerable since the fall. Before the accident, his chronic pain from a previous injury and medical procedure was manageable despite reaching an 8 out of 10. Now it consistently hit 9 out of 10, only dropping to 6 out of 10 with pain medication.
"The pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm," the resident explained. He said the pain medication wasn't adequately managing his symptoms.
The day after the fall, a nurse documented telling the resident that his x-ray results were negative. But that assessment was premature and incomplete.
On August 16, more than three weeks after the accident, a nurse finally called the radiology company to follow up on the incomplete results. The company explained that the x-ray notes from July 25 stated "lateral view was unattainable due to patient's inability to position." The radiologist told the nurse that "a lateral view is necessary for all spinal x-rays."
Without the complete imaging study, the facility couldn't rule out injury from the fall.
The Director of Nursing told inspectors she wasn't aware the x-ray results were incomplete until the inspection. She said she would follow up with the radiology company to obtain the missing results. "An injury could not be ruled out until the x-ray results were obtained," she acknowledged.
Meanwhile, the resident's pain management remained inadequate. A July 29 nurse note documented that the resident "verbalizes oxycodone/APAP per prn ineffective yet no further requests for pain medication which he normally will request."
By August 15, the resident had been prescribed oxycodone oral solution, 15 ml every four hours as needed for pain.
The incomplete documentation violated the facility's own policies. According to Majestic Mountain's 2017 charting and documentation procedures, all services provided to residents and changes in their medical condition must be documented completely and accurately in the medical record.
The policy specifically requires documentation of "objective observations," "treatments or services performed," "changes in the residents condition," and "events, incidents or accidents involving the resident." Documentation must include "the date and time the procedure/treatment was provided" and "the assessment data and/or any unusual findings obtained during the procedure/treatment."
The Director of Nursing told inspectors that all facility nurses should have followed proper documentation procedures, including full completion of the resident's SBAR communication tool and progress notes. She said nurses had been educated on the importance of complete and accurate documentation.
But the education apparently didn't prevent the breakdown in follow-up care. For more than three weeks, the resident endured worsening pain while the facility operated under the false assumption that his x-rays had ruled out injury from the fall.
The inspection found that few residents were affected by the documentation failures, and the level of harm was classified as minimal or potential for actual harm. But for the resident who fell, the impact was significant. His chronic pain condition, previously tolerable at an 8 out of 10, became unmanageable after the nursing assistant's error sent him tumbling backward from his wheelchair.
The resident continues to experience pain levels of 9 out of 10, with only partial relief from medication that he says isn't adequately controlling his symptoms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Mountain Care Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MAJESTIC MOUNTAIN CARE CENTER in OAKHURST, CA was cited for violations during a health inspection on September 12, 2025.
The July 25 accident at Majestic Mountain Care Center left the resident with pain radiating down his spine into both arms.
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.