Health inspection·January 30, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Progress Note, dated 1/30/2025, the progress note indicated, . On January 25, 2025, at 6:00 p.m., this writer was called to [Resident 1] room. Two CNAs were assisting [Resident 1] to pull up in bed so she could eat her dinner. [CNA 2] stated [Resident 1], who cut your hair? [Resident 1] had a puzzled look and did not know what she was talking about. [CNA 2] pointed out that [Resident 1] hair was shorter than when she last saw it. This writer had no knowledge of [Resident 1] receiving a haircut as [Resident 1] preference was to keep her hair long. This writer had regularly provided care to [Resident 1] for many months and [Resident 1] had always denied any haircuts as she wanted to donate her hair to a charity. [Resident 1] stated that she was unaware her hair was cut and did not give anybody consent to cut her hair. [Resident 1] was observed to be visibly upset that her hair was cut without her consent. Upon observation, this writer observed that a minimum of seven inches was cut from [Resident 1] hair. After an amount of time, it was soon learned that [CNA 1] was the one who cut [Resident 1] hair. [CNA 3] witnessed the alleged incident . During an interview on 1/30/2025 at 11:19 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/25/2025, CNA 2 was heard asking Resident 1 if she had cut her hair. LVN 1 stated Resident 1's hair being cut was out of the ordinary because Resident 1 had requested to not cut her hair. LVN 1 stated she had observed Resident 1's hair braided but the hair tips indicated Resident 1's hair was recently cut. LVN 1 stated she asked Resident 1 if she had requested a haircut in which Resident 1 replied, No. LVN 1 stated Resident 1's hair was longer than hip length prior to the haircut and was now below the shoulder. LVN 1 stated she began investigating the occurrence and discovered CNA 3 had witnessed CNA 1 cutting Resident 1's hair in the shower. LVN 1 stated she felt sad for Resident 1 and felt CNA 1 had violated Resident 1's rights. LVN 1 stated for Resident 1, growing her hair was an important choice that was taken from her by CNA 1. During a review of Resident 1's Interdisciplinary Team (IDT) Note, dated 1/27/2025, the note indicated, . [CNA 2] pointed out that [Resident 1] hair was shorter than when she last saw it. [LVN 1] had no knowledge of [Resident 1] receiving a haircut as [Resident 1] preference is to keep her hair long. [LVN 1] has regularly provided care to [Resident 1] for many months and [Resident 1] has always denied any haircuts as she wanted to donate her hair to a charity. [Resident 1] stated that she was unaware her hair was cut and did not give anybody consent to cut her hair . [Resident 1] was spoken to when incident was discovered, and resident stated she was upset but not much can be done at this time just wished to no longer work with [CNA 1] . During an interview on 1/30/2025 at 11:50 a.m. with the social services director (SSD), the SSD stated she had met with Resident 1 following the incident on 1/25/2025. The SSD stated Resident 1 had expressed feelings of being violated and angry following the incident. The SSD stated Resident 1 made facility staff aware of her preference to grow her hair. The SSD stated Resident 1's choice should have been respected. During a review of Resident 1's Progress Note Social Services, dated 1/28/2025, the progress note indicated, . Visited with resident today, follow up (f/u) from hair cut incident. She told me she was still upset, feels violated, and does not want that CNA in her room . During a review of Resident 1's Progress Note Social Services, dated 1/29/2025, the progress note indicated, . Visited with resident today. She appeared less irritable regarding recent haircut. Did mention again, she does not want that CNA near her . During an interview on 1/30/2025 at 12:35 p.m. with CNA 2, CNA 2 stated she had observed Resident 1's hair was cut shorter. CNA 2 stated she asked Resident 1 if she had a recent haircut in which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 2 of 6 Printed: 05/15/2026 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 555115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Resident responded, No. CNA 2 stated CNA 1 was caring for Resident 1 CNA 2 stated CNA 3 had reported observing CNA 1 cutting Resident 1's hair in the shower. CNA 2 stated she recalled Resident 1's hair had grown below her hip and was now at shoulder length. CNA 2 stated Resident 1 always informed staff of her hair and how she was growing it to donate it. CNA 2 stated it was important to respect Resident 1's right to personal preference due to the potential for emotional harm. Residents Affected - Few During an interview on 1/30/2025 at 12:51 p.m. with the director of staff development (DSD), the DSD stated CNA 1 had been in serviced on abuse and resident rights. The DSD stated when CNA 1 cut Resident 1's hair, it was a form of emotional abuse and violation of Resident 1's rights. The DSD stated Resident 1's choice to grow her hair was known to the facility staff. The DSD stated it was important to respect and follow Resident 1's personal preference and beliefs because they were a representation of her wellbeing. The DSD stated Resident 1 had the potential to feel upset and experience depressed feelings. During an interview on 1/30/2025 at 1:19 a.m. with the assistant director of nursing (ADON), the ADON stated the facility identified the incident on 1/25/2025 when Resident 1's hair was cut by CNA 1, as a form of physical and emotional abuse. The ADON stated, Resident 1's personal preference for growing her hair should have been respected by all staff in the facility. The ADON stated, when Resident 1's hair was cut, there was risk for psychosocial harm. During a telephone interview on 1/31/2025 at 10:53 a.m. with CNA 3, CNA 3 stated she recalled CNA 1 cutting Resident 1's hair on one occasion prior to 1/25/2025. CNA 3 stated CNA 1 was observed cutting Resident 1's hair in the bathroom following Resident 1's scheduled shower. CNA 3 stated a shower bed was required to shower Resident 1. CNA 3 stated the shower bed allowed Resident 1's hair to hang freely at the edge. CNA 3 stated CNA 1 cut Resident 1's hair while CNA 3 was blow drying Resident 1's hair. CNA 3 stated she had questioned CNA 1 regarding the cutting of Resident 1's hair but CNA 1 assured CNA 3 It was ok she always cut her hair. CNA 3 stated she was not familiar with Resident 1 therefore she did not question CNA 1. CNA 3 stated after the shower, CNA 1 braided Resident 1's hair and continued with her job routine as usual without mentioning the haircut to Resident 1. Following the incident on 1/25/2025, CNA 3 stated CNA 1 had told her not to say anything about what she had seen when she cut Resident 1's hair in the shower on the previous occasion. CNA 3 stated prior to 1/25/2025, Resident 1's hair was at lower back length and after 1/25/2025 it was significantly shorter reaching below the shoulder in length. During a telephone interview on 1/31/2025 at 11:01 a.m. with CNA 1, CNA 1 stated she had worked in the facility for almost 2 years and had cared for Resident 1 at least every 2 months until 1/25/2025. CNA 1 stated she was familiar with Resident 1 and her preference to grow her hair. CNA 1 stated she had not cut Resident 1's hair on 1/25/2025 or any time before that date. CNA 3 stated she knew how much Resident 1 loved her hair and would not have cut her hair. CNA 1 stated that everyone in the facility wanted to cut Resident 1's hair because it was too much work to maintain it. CNA 1 stated that prior to 1/25/2025, Resident 1's hair length was to her lower back and on 1/25/2025 it was to her shoulder length. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/2022, the P&P indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 3 of 6 Printed: 05/15/2026 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 555115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident abuse . instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . willful means the individual must have acted deliberately . During a review of the facility's P&P titled, Resident Rights, dated 2022, the P&P indicated, . The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . the resident has the right to be informed of, and participate in, his or her treatment, including . the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care . the right to be informed, in advance, of changes to the plan of care. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care . the resident has the right to be treated with respect and dignity, including . the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including .the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . Event ID: Facility ID: 555115 If continuation sheet Page 4 of 6 Printed: 05/15/2026 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 555115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet psychosocial needs according to the policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of four sampled Residents (Resident 1), when Resident 1 ' s preference to grow her hair to donate to charity was not documented as part of the plan of care in the care plan. This failure resulted in psychosocial and emotional harm for Resident 1, when her hair was deliberately cut by certified nursing assistant (CNA) 1 and stated she was feeling betrayed, angry and sad. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for dysphagia (difficulty swallowing), communication deficit, major depressive disorder (condition manifested by persistent sadness, loss of interest), multiple sclerosis (condition causing nerve damage disrupting function between the brain and body), muscle weakness, contracture (tightening of muscles, tendons, ligaments and skin) of left and right ankle. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 10/17/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 1/30/25 at 10:11 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 was observed lying in bed with hair observed in a ponytail. Resident 1 stated she had been growing her hair since admission in 2018 in order to donate it. Resident 1 stated that she shared her desire to grow her hair with all staff caring for her in the facility. Resident 1 stated that on 1/25/25, CNA 2 discovered that Resident 1 ' s hair was cut. Resident 1 stated her hair was at hip length prior to CNA 1 cutting her hair. Observation of Resident 1 visibly crying when positioning hair forward to show hair was now shoulder length. Resident 1 stated she felt betrayed, angry and sad following the cutting of her hair. During a concurrent interview and record review on 1/30/25 at 11:46 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s electronic medical record (EMR) for Care Plans were reviewed. The EMR indicated there was no care plan for Resident 1 ' s preference to grow her hair for donation to charity. LVN 1 stated that on 1/25/25, CNA 2 was heard asking Resident 1 if she had cut her hair. LVN 1 stated Resident 1 ' s hair being cut was out of the ordinary because Resident 1 had requested to not cut her hair. LVN 1 stated she had observed Resident 1 ' s hair braided but the hair tips indicated Resident 1 ' s hair was recently cut. LVN 1 stated she asked Resident 1 if she had requested a haircut in which Resident 1 replied, No. LVN 1 stated Resident 1 ' s hair was longer than hip length prior to the haircut and was now below the shoulder. LVN 1 stated she felt sad for Resident 1 and felt CNA 1 had violated Resident 1 ' s rights. LVN 1 stated for Resident 1, growing her hair was an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 5 of 6 Printed: 05/15/2026 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 555115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few important choice that was taken from her by CNA 1. LVN 1 stated it was important to document and care plan Resident 1 ' s personal preference to grow her hair to respect Resident 1 ' s decisions. LVN 1 stated it was important to document a personal preference to avoid situations such as the cutting of Resident 1 ' s hair and causing Resident 1 preventable anguish. During a concurrent interview and record review on 1/30/25 at 11:50 a.m. with the social services director (SSD), Resident 1 ' s EMR for Care Plans were reviewed. The EMR indicated there was no care plan for Resident 1 ' s personal preference to grow her hair for donation to charity. The SSD stated when Resident 1 voiced her personal preference it should have been care planned with interventions to include Resident 1 ' s desire to not have her hair cut. The SSD stated Resident 1 voiced her preference to all staff caring for her throughout the years. The SSD stated it was important to have a care plan to address Resident 1 ' s preferences to provide Resident 1 with proper care. During an interview on 1/30/25 at 12:19 p.m. with LVN 2, LVN 2 stated it was the facility process to document all residents personal preferences in the care plan. LVN 2 stated it was important to care plan preferences to plan Resident 1 ' s care accordingly. LVN 2 stated there was a potential for Resident 1 to become angry and upset when Resident 1 ' s personal preference was not documented in the care plan. During a concurrent interview and record review on 1/30/25 at 12:51 p.m. with the director of staff development (DSD), Resident 1 ' s EMR for Care Plans was reviewed. The EMR indicated there was no care plan for Resident 1 ' s personal preference to grow her hair for donation to charity. The DSD stated Resident 1 ' s preference to grow her hair should have been care planned and individualized for Resident 1 ' s plan of care. The DSD stated, Resident 1 ' s preference to grow her hair verbalized by Resident 1 to staff who provided care. During an interview on 1/30/25 at 1:19 p.m. with the director of nursing (DON), the DON stated it was the facility process to care plan all Resident ' s personal preferences with care. The DON stated, Resident 1 ' s preference to grow her hair and donate it to charity should have been care planned with interventions. The DON stated there was no excuse to not have completed a care plan for Resident 1 ' s hair growth. The DON stated, Resident 1 ' s preference should have been respected and had the potential to cause psychosocial harm. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Each resident ' s comprehensive person-centered care plan is consistent with the resident ' s rights to participate in the development and implementation of his or her plan of care, including the right to . participate in establishing the expected goals and outcomes of care . The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being, including . services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . includes the resident ' s stated goals upon admission and desired outcomes . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 6 of 6