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Majestic Mountain Care: Pain Management Failures - CA
The pain crisis at Majestic Mountain Care Center began July 25, 2025, when the resident fell....
Latest reports, citations, and penalties from CMS data
The pain crisis at Majestic Mountain Care Center began July 25, 2025, when the resident fell....
The September 10 incident at Hyde Park Healthcare Center violated the facility's own infection control policies and basic wound care protocols....
The resident, who also suffered from anxiety disorder and failure to thrive, sustained two skin tears to her right knee during the June 17 incident....
The August incident involved Resident 4, whose cognition was moderately impaired according to facility assessments....
The September inspection found Resident 4 awake, fidgeting and visibly uncomfortable at 11:20 p.m....
"I hate the holes in the wall there," one resident told inspectors while walking upstairs past damaged wallboard....
But the facility's own administrator admitted they failed to develop and implement proper discharge planning....
Multiple staff members witnessed her verbally abusing residents and refusing to provide care....
The facility also lost track of neurologist consultation notes from July 30, 2025, leaving staff without specialist guidance for the resident's condition....
She verified there was no dietitian documentation in February after the weight loss had been identified, and no documentation in March....
Resident 3 lived at Courtyard Care Center with anoxic brain damage caused by lack of oxygen to the brain....
The assault at Westview Healthcare Center prompted administrators to assign the aggressive resident a full-time sitter....
The September 8 incident revealed a fundamental flaw in the facility's security system....
The resident had been admitted for follow-up care after a surgical procedure, along with heart failure and dementia....
The resident, identified only as Resident 1 in inspection records, was transferred to GACH hospital on September 2nd....
State inspectors observed the violation at Avir at Borger on August 26, 2025, during a complaint investigation....
The resident, admitted with chronic pain syndrome and rheumatoid arthritis, had two clear physician orders that went unfulfilled....
The facility's infection control breakdown came to light during a September 11 complaint investigation....
Sign-in sheets from meetings on March 11, April 8, July 8, and August 12 showed no signature from the infection control expert....
In resident R1's room, the thermostat displayed no temperature readings....