Majestic Mountain Care Center
MAJESTIC MOUNTAIN CARE CENTER in OAKHURST, CA — inspection on September 12, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Mountain Care Center
40131 Highway 49 Oakhurst, CA 93644
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Majestic Mountain Care Center
40131 Highway 49 Oakhurst, CA 93644
SUMMARY STATEMENT OF DEFICIENCIES
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 .
Facility ID: