Majestic Mountain Care Center: Hip Fracture After Staff Left - CA
The man fractured his hip.
Federal inspectors cited Majestic Mountain Care Center following a complaint investigation completed April 28, 2026. The citation involved at least two residents and centered on a fall that ended with a broken bone and a care team that, by its own documentation, had simply failed to return.
The resident, identified in inspection records as Resident 1, had bilateral above-the-knee amputations and a documented preference for keeping his bed at a high level, a combination that the facility's own fall review team listed as risk factors. His cognitive assessment placed him at a score of 14 out of 15, meaning he was largely intact mentally. He needed substantial physical help, the kind where a helper does more than half the work, lifting and holding limbs and trunk.
The facility's fall interdisciplinary team review told the story in fragments, the way clinical notes do. A treatment nurse stepped away from the room. Resident 1 was left on his right side while awaiting her return. She never showed up.
What happened next was documented in a radiology report: fracture involving the left femoral trochanters, the bony prominence at the top of the thigh bone where the hip joint bears weight and absorbs impact. It is a serious injury in any patient. In a man with no legs below the knee, already dependent on staff for repositioning, already flagged as a fall risk, it was the consequence of someone not coming back.
His medication record from April showed he had been receiving acetaminophen for pain in the days around the incident, at doses of 325 milligrams, for pain ratings that ranged from 2 to 4 on whatever scale the facility used. The pain was being managed. The fall risk, apparently, was not.
The second resident named in the inspection, Resident 2, had a cognitive assessment score of 7, placing them in the range of severe impairment. The inspection records do not describe a specific incident involving Resident 2, but their inclusion in a citation about the quality of care delivered suggests inspectors found the facility's failures extended beyond a single afternoon and a single nurse who walked out of a room.
The facility had a written policy. It was called Provision of Quality Care. It said the facility would ensure residents receive treatment and care in accordance with professional standards of practice. Inspectors reviewed it. They cited the facility anyway.
CMS classified the harm level as minimal harm or potential for actual harm, which is the lower tier of the federal violation scale. That classification will strike some readers as difficult to reconcile with a broken hip. Federal inspectors use the phrase to indicate that harm occurred or could have occurred but did not rise to the threshold of immediate jeopardy, the designation reserved for situations where inspectors believe death or serious injury is likely without immediate correction. A fractured femoral trochanter in a bilateral amputee who was left unattended apparently fell below that line.
What the inspection record does not contain is any account of how long Resident 1 waited on his side before someone found him, or whether anyone was ever asked why the treatment nurse did not return, or what the facility told his family. The fall review notes end where the clinical documentation ends. She never showed up. The x-ray was done. The fracture was there.
Resident 1 had scored a 14 on his cognitive assessment. He knew where he was. He knew he had no legs. He knew someone had left him on his side and said they were coming back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Mountain Care Center from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MAJESTIC MOUNTAIN CARE CENTER in OAKHURST, CA was cited for violations during a health inspection on April 28, 2026.
Federal inspectors cited Majestic Mountain Care Center following a complaint investigation completed April 28, 2026.
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.