Majestic Mountain Care Center

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. The DON stated all nurses in the facility should have followed

the process for documenting including the full completion of Resident 1's SBAR and progress note. The DON stated the nurses had been educated on the importance of complete and accurate documentation in

the facility.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area, had now exacerbated since the fall. Resident 1 stated, because 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. Resident 1 stated that prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated that his pain level decreased to 6/10 with pain medication since the fall.

Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has

a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request.During a review of Resident 1's, Order Summary Report, dated 8/15/25, the report indicated, . Oxycodone oral solution. give 15 ml (unit of measure) every 4 hours as needed for pain. During

a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of

the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary (IDT) team regarding the resident's condition and response to care. the following information is to be documented

in the resident medical record, objective observations. treatments or services performed, changes in the residents condition, events, incidents or accidents involving the resident. documentation in the medical

record will be objective, not opinionated or speculative, complete and accurate. documentation of procedures and treatments will include care-specific details, including, the date and time the procedure/treatment was provided. the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Mountain Care Center

40131 Highway 49 Oakhurst, CA 93644

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm

prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Majestic Mountain Care Center

40131 Highway 49 Oakhurst, CA 93644

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in order to achieve proper pain management for Resident 1 which was not done.During a concurrent

interview and record review on 8/29/25 at 11:20 a.m. with LVN 2, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, .

Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which

he normally will request. LVN 2 stated, Resident had complained of 10/10 pain to his back during the day.

LVN 2 stated Resident 1's pain levels ranged between 8-10/10 pain on a daily basis. LVN 2 stated the progress notes indicated Resident 1 was experiencing an increase in pain with unrelieved pain with medications ordered. LVN 2 stated the facility process was to complete an assessment of Resident 1, document in the EMR, and notify the physician of Resident 1's ineffective pain medication and increased pain. LVN 2 stated Resident 1's pain was not properly managed following the fall on 7/25/25.During a

review of the facility's policy and procedure (P&P) titled, Pain Management, dated, 9/2/22, the P&P indicated, . The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. the facility will Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon. a significant change in condition or status occurs. Manage or prevent pain, consistent with. current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident. Identifying key characteristics of the pain, Duration of pain, Frequency, Location, Timing, Pattern (e.g. constant or intermittent), Radiation of pain, Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms).

The resident's goals for pain management and his/her satisfaction with the current level of pain control.

Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion .

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Facility ID:

If continuation sheet