Health inspection·July 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete should have been fixed as soon as possible so Resident 22 could have returned to her old room. The AIT stated it was important to honor Resident 22's right. The AIT stated the facility was Resident 22's home and she had the right to be comfortable in her room. During a review of Resident 22 s admission Record (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 22 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (debilitating disease that affects the central nervous system (brain and spinal cord), muscle weakness, pain, dysphagia (difficulty swallowing), and shortness of breath.During a review of Resident 22s Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/13/25, the MDS, indicated Resident 22's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 22 was cognitively intact.During a review of the facility's Maintenance Request Form (MRF), dated 6/5/25, the MRF indicated, .Issue needing attention: call light rest button not working. During a record review of the facility's policy and procedure (P&P) dated, 12/2016, the P&P indicated, .Federal and state laws guarantee certain basic rights to all resident of this facility. These rights included the residents' rights to: c Be free from.misappropriation of property.e: Self-Determination [having the right to control one's own life and [NAME], encompassing the ability to make choices, set goals, and advocate for oneself] . Event ID: Facility ID: 555115 If continuation sheet Page 2 of 31 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 07/24/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, comfortable, homelike environment for four of 19 sampled residents (Resident 12 , 16. 31 and 38) when:1. Resident 12 was not provided with a mattress that was comfortable for him.This failure caused Resident 12 to be uncomfortable and not receive restful sleep.2. Resident 31 and Resident 38's room had two white painted patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door leading to the corridor.This failure had the potential for Resident 31 and Resident 38 to feel depressed and was not homelike environment.3. Resident 31 and Resident 38 shared restroom that had brown like substance on the seat of the toilet, personal items on the floor and top of the toilet. This failure had the potential for Resident 31 and Resident 38 to have cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and a not homelike environment.4. Resident 16's bathroom, had strong smell of urine when entering the room and the bathroom had urine and trash on the floor around the toilet.This failure had the potential for Resident 16 to have cross-contamination and a not homelike environment.5. Resident 54 was observed laying directly on the mattress of her bed without a sheet.This failure had the potential to cause Resident 54 to feel uncomfortable and depressed by leaving her bed without bedding and not providing a homelike environment. Findings:1. During an interview on 7/21/25 at 10:55 a.m. with Resident 12, Resident 12 stated his mattress was too small for him. Resident 12 stated he was six feet and seven inches tall and weighed 350 pounds, so the mattress did not provide him with a comfortable night's rest. Resident 12 stated the mattress had worn down a lot in the middle and it caused him to feel all the springs and metal from the bed frame.During an interview on 7/24/25 at 10:03 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 12 was a larger person, and a larger bed should have been supplied to him. LVN 1 stated there were other large residents with bigger beds in the facility so Resident 12 should also have a larger bed. LVN 1 stated it was important to provide Resident 12 with a larger bed because it ensured he was provided with a comfortable resting environment.During an interview on 7/24/25 at 11:33 a.m. with the Maintenance Supervisor (MS), the MS stated Resident 12 should have had his bed replaced if he expressed discomfort with his current bed. The MS stated it was important to provide Resident 12 with a different bed because it ensured he was comfortable and well rested, and since he was a bigger person he needed a mattress that could better accommodate him.During an interview on 7/24/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 should have been provided a different bed if he needed it, he is a large person and would benefit from having a comfortable mattress.During an interview on 7/24/25 at 2:44 p.m. with the Administrator in Training (AIT), the AIT stated residents in the facility were entitled to a comfortable bed and a restful sleep, it was their right to have a comfortable homelike environment provided to them.During an interview on 7/24/25 at 2:17 p.m. with the Director of Nursing (DON), the DON stated Resident 12's bed was older, and it did not provide the support he required to be comfortable. The DON stated the mattresses for all the resident's needed to be in good working conditions.During a review of the facilities policy and procedure (P&P) titled, Homelike environment, dated 12/19/22, the P&P indicated. In accordance with resident's rights, the facility will provide a safe ,clean, comfortable and homelike environment . a determination of ‘homelike' should include the residents opinion of the environment.2. During an interview on 7/21/25 at 10:34 a.m. in Resident 38's room, Resident 31's and Resident 38's room had two white paint patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door. Family Member (FM) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 3 of 31 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 07/24/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 stated she had offered to paint the room. FM 1 stated she felt the room was depressing and did not look homelike.During an observation and interview on 7/23/25 at 12:19 p.m. with the Lead Certified Nursing Assistant (LCNA), the LCNA stated the walls in the room had two different tones of paint. The LCNA stated the room was tacky and unfinished. The LCNA stated the room could have caused residents to feel depressed. The LCNA stated the room should have been painted all one color.During an interview on 7/23/25 at 3:30 p.m., with the AIT, the AIT stated the room should have been painted. The AIT stated residents could have been unhappy about the room being unfinished. The AIT stated it could have caused residents to be upset. The AIT stated the room could have caused residents to be depressed and the facility should have made the room homelike. The AIT stated the white painted patches on the wall were not a homelike environment. During a review of Resident 31's admission Record (AR) (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), acute respiratory failure (life-threatening lung disease) and heart failure (a condition when the heart can't pump enough blood to meet the body's needs).During a review of Resident 31 Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/9/25, the MDS, indicated Resident 31's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 4 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 31 was severely cognitively impaired.During a review of Resident 38 s AR dated 7/24/25, indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness), lower back pain, dysphagia (difficulty swallowing), heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 38s MDS dated [DATE], the MDS, indicated Resident 38's had a BIMS score of 15 indicating Resident 38 was cognitively intact.During a review of the facility's P&P titled, Safe and Homelike Environment dated 12/19/2022, the P&P indicated, .In accordance with resident's rights, the facility will provide a safe, clean and comfortable and homelike environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. 3. During an interview on 7/21/25 at 10:34 a.m., with Family Member (FM) 1, FM 1 stated the restroom was dirty and unacceptable. FM 1 stated the restroom was shared with other Residents and was concerned about infection control. During a concurrent observation and interview on 7/21/25 at 11:46 a.m., in Resident 31 and Resident 38's restroom with the LCNA, a brown substance was observed on the toilet seat, a bag of adult brief, a urinal hat and a commode bucket was on the ground, two bags of wipes and a bottle of lotion was on the top of the toilet, and a trash bin did not contain a bag liner. The LCNA stated none of it should have been there. The LCNA stated bag of briefs and lotion should have been in the resident personal closet. The LCNA stated the commode bucket, urinal hat should have been put on the ground and should have been stored away. The LCNA stated trash cans should have a bag liner, and the toilet should be cleaned and not contain feces (brown like substance) on the seat. The LCNA stated CNAs should have cleaned and housekeeping should have disinfected the toilet. The LCNA stated residents were at risk for cross-contamination when they used the restroom. During an interview on 7/24/25 at 3:40 p.m., with the Infection Preventionist, (IP-healthcare professional specializing in the surveillance, control and prevention of infections), the IP was shown a photo of the restroom. The IP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 4 of 31 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 07/24/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the briefs should have been in the resident closet and not on the floor. The IP stated, the commode should not have been on the toilet. The IP stated the lotion, urinal hat, wipes should not have been in the restroom. The IP stated the feces on the toilet were unsanitary and not a home-like environment. The IP stated residents who use the toilet were at risk for cross-contamination and could have been upset from the restroom being filthy. The IP stated it was the facility's responsibility to ensure the restroom was clean and homelike. During an interview on 7/24/25 at 3:47 p.m., with the DON, the DON stated the dirty restroom was not homelike. The DON stated the CNA should have cleaned it and organized it. The DON stated the dirty restroom was an infection control issue and there could have been cross-contamination. The DON stated residents should not have a dirty restroom. The DON stated the restroom should have been cleaned. The DON stated the dirty restroom was not a homelike environment. During a review of Resident 31 s AR dated 7/24/25, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of dementia, acute respiratory failure, and heart failure.During a review of Resident 31 MDS dated [DATE], the MDS, indicated Resident 31's had a BIMS score of 4 indicating Resident 31 was severely cognitive impaired.During a review of Resident 38 s AR dated 7/24/25, indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of anxiety, lower back pain, dysphagia, heart failure, and anemia.During a review of Resident 38s MDS dated [DATE], the MDS, indicated Resident 41's had a BIMS score of 15 indicating Resident 38 was cognitively intact.During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment dated 12/19/2022, the P&P indicated, .In accordance with resident's rights, the facility will provide a safe, clean and comfortable and homelike environment.Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. During a review of the facility's P&P titled, Policy and Procedure on Housekeeping and Facility Cleanliness undated, the P&P indicated, .Purpose: To ensure the cleanliness and safety of the facility by maintaining high standards of sanitation and hygiene in compliance with state regulations and infection control guidelines.This policy applies to all housekeeping staff, nursing staff and other personnel involved in cleaning and maintaining the facility environment.Bathrooms (Resident and Public): .clean and disinfect toilets. 4. During a concurrent observation and interview on 7/21/25 at 11:46 a.m., with resident 16 in Resident 16's bathroom, a strong odor of urine was noted as well as yellow liquid on the floor around the toilet, and trash was seen on the floor. Resident 16 stated, The bathroom has not been cleaned for a long time, and it has always smelled of urine, I have had to get used to the smell.During an interview on 7/21/25 at 12:10 p.m., with LVN 1, in Resident 16's room, LVN 1 stated she could smell urine in the room and the resident should not have to get used to the smell of urine. LVN 1 stated Resident 16 had the right to have a clean and odor-free bathroom. LVN 1 stated having a dirty bathroom could discourage residents from using the bathroom resulting in more bowl and bladder accidents and the possibility of skin breakdown.During an interview on 7/24/25 at 1:20 p.m., with the MS, the MS stated, the bathroom was not up to his expectation. The MS stated it was his expectation for the residents' bathrooms to be cleaned once per day and as needed. The MS stated the bathroom did not Provide Resident 16 with a homelike environment. During an interview on 7/24/25 at 3:00 p.m., with the AIT, the AIT stated, The bathroom did not look like it had been cleaned, it is the responsibility of housekeeping to clean the bathrooms and the whole staff to monitor the bathrooms and resident rooms to notify housekeeping when they need to be cleaned. The bathroom does not meet expectations.During a review of Resident 16's AR dated 7/24/25, indicated Resident 16 was admitted to the facility on [DATE] with the following diagnosis, alcohol induced dementia (ARBD- a form of brain damage caused by long-term heavy drinking), muscle weakness, COPD, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 5 of 31 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 07/24/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete anxiety disorder.During a review of Resident 16's MDS section C, dated 7/01/25, the MDS, indicated Resident 16's had a BIMS score of 10 indicating Resident 16 had moderate cognitive impairment.During a review of the facility's P&P titled, Policy and Procedure on Housekeeping and Facility Cleanliness undated, the P&P indicated, .Purpose: To ensure the cleanliness and safety of the facility by maintaining high standards of sanitation.5. During a concurrent observation and interview on 7/21/25 at 11:53 a.m., with CNA 3, in Resident 54's room, Resident 54 was observed lying directly on the mattress of her bed without bed sheets, pillowcase, or blankets. CNA 3 stated the CNA that gave her report told her that the resident was pulling at the sheets and putting them over her face, therefore CNA removed the sheets from the bed. CNA 3 stated she did not put sheets on the bed because she was following the instruction of the previous nurse. During a concurrent observation and interview on 7/21/25 at 11:56 a.m. with Licensed Vocational Nurse (LVN)1, LVN1 stated, The sheets should not have been removed from Resident 54, Resident 54 should have been re directed, put in a wheelchair, or something other than removing her sheets.During an interview on 7/23/25 at 10:45 a.m. with the Director of Staff Development (DSD), the DSD stated, Resident 54 should not be left on the bed without sheets, it is violation of her rights, and comfort. CNA 3 should have discussed the situation with LVN 1 and found a solution that did not leave Resident 54 lying on the bare mattress. During an interview on 7/23/25 at 1:10 p.m., with the AIT, the AIT stated Leaving Resident 54 on the bare mattress is unacceptable and the staff should have found another way to work with Resident 54's behavior.During a review of Resident 54's AR dated 7/24/25, the AR indicated Resident 54 was admitted to the facility on [DATE] with the following diagnosis: Alzheimer's Disease (a brain disorder that causes a progressive decline in memory, thinking, and reasoning skills), Dementia (a decline in mental ability, severe enough to interfere with daily life), Major Depressive Disorder (a serious mental illness characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly interferes with daily life) and Osteoarthritis (a common joint condition where the protective cartilage between bones breaks down).During a review of Resident 54 MDS dated [DATE], the MDS, indicated Resident 54's had a BIMS score of 0 indicating Resident 54 had severe cognitive impairment.During a review of the facilities P&P titled, Homelike environment, dated 12/19/22, the P&P indicated. In accordance with resident's rights, the facility will provide a safe ,clean, comfortable and homelike environment . a determination of ‘homelike' should include the residents opinion of the environment. Event ID: Facility ID: 555115 If continuation sheet Page 6 of 31 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 07/24/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 19 sampled residents (Resident 41), when Resident 41 experienced an unplanned weight loss of six pounds (3.4%) in one month (2/1/25-3/1/25), nine pounds (5.3%) in one month (5/1/25-6/1/25), and 23 pounds (13.7%) in five months (2/1/25 - 7/7/25), and interventions to prevent weight loss were not recommended and implemented in a timely manner. In addition, nursing staff did not notify the physician, notify Resident 41's responsible party (RP), schedule an inter-disciplinary team (IDT-a group of professionals from different fields who collaborate to achieve a common goal) meeting to determine the cause of the weight loss in accordance with professional standards of practice and the facility's policy and procedure, Weight Management Policy .These failures had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), loss of independence, and decreased quality of life.Findings:During a review of Resident 41 s admission Record (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 41 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty in swallowing), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety (a feeling of unease, worry or fear) and unspecific protein-caloric malnutrition ( a condition resulting from insufficient intake of protein and/or calories). During a review of Resident 41s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/7/25, the MDS, indicated Resident 41's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 41 was unable to complete the interview.During a review of Resident 41's MDS section GG (standardized functional assessment used in all post-acute care settings to measure self-care and mobility) dated 3/2/25, the MDS indicated Resident 41 required partial/moderate assistant (helper does less than 1/2 e) with eating.During a review of Resident 41's MDS section GG dated 5/29/25, the MDS indicated Resident 41 required substantial/maximum assistance with feeding (helper does more than 1/2 ) with eating.During a review of Resident 41's MDS dated 7/7/25, the MDS indicated Resident 41's weight was 153 pounds and was not on physician prescribed weight loss regimen. During a record review of Resident 41's Weights and Vitals Summary from 2/1/25 to 7/7/25, the following monthly weights for Resident 41 were shown:2/1/25: 176 lbs (pounds-unit of measurement):3/1/25: 170 lbs (3. 4%, -6 lbs weight loss in 30 days compared to previous month 176 lbs.).4/1/25: 171 lbs5/1/25: 169 lbs6/1/25: 160 lbs (5.3% , 9 lbs weight loss in 1 month compared to previous month 169 lbs)6/23/25: 156 lbs (2.5%, -4 lbs in 3 weeks compared to 160 lbs on 6/1/25)7/7/25: 153 lbs (13.7%, 23 lbs weight loss compared to 176 lbs on 2/1/25).7/14/25: 151 lbsDuring an observation on 07/21/2025 at 10:22 a.m. in Resident 41's room, Resident 41 was lying in her bed. Resident 41 was dressed in a gown. Resident 41 was not able to state her name and was not interviewable. During a concurrent interview and record review on 7/23/25 11:47 a.m., with License Vocational Nurse (LVN), Resident 41's RD's Progress Notes (PN) dated 7/15/25 was reviewed. The PN indicated, .Dietary: 7/7: 153lb, 3 lb weight loss x 2 weeks (6/26:156lb) and significant 14% 25 lb weight loss x 6 month (1/1/:178lb) .IDT recommendation: continue with plan of care and monitor weekly weight x 1 week. LVN 1 stated an IDT should have discussed Resident 41's weight loss. LVN 1 stated the IDT should have Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 7 of 31 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 07/24/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few recommended any changes for the residents and the nurses should have followed the recommendations. LVN 1 stated she was not aware she had to notify the physician of Resident 41's weight loss on 6/1/25 and 7/7/25. During an interview and record review on 7/24/25 at 2:20 p.m. with the Registered Dietitian (RD), the RD stated Resident 41 had a six-pound weight loss in one month on 3/1/25. The RD stated the facility should have had an IDT meeting in the month of 3/1/25 and was not done. The RD stated she should have made recommendations for weekly weight check in 3/2025. The RD stated on 6/1/25 Resident 41 had a nine-pound weight loss. The RD stated on 6/12/25 there was an IDT meeting and Resident 41 was added to the weekly weight and weight variance program (system for monitoring and addressing significant weight changes in residents, especially weight loss, to ensure their health and well-being). The RD stated Resident weight was 160 lbs on 6/1/25 and on 6/23/25 her weight was 156 lb. The RD stated Resident 41 had four pounds weight loss in three weeks. The RD stated Resident 41 was started on Prostat (collagen protein medical food used to address increased protein needs in individuals with conditions like pressure injuries, wounds, and protein-energy malnutrition) for supplement on 7/21/25. The RD stated Resident 41 had a significant weight loss and should have additional supplement on 6/25. The RD stated the facility should have done a diabetic oral supplement to prevent weight loss. The RD stated she did not do all the interventions to prevent weight loss. The RD stated the physician should have been notified of the weight loss on 6/1/25. During an interview on 7/24/25 at 2:50 p.m. with the Speech Therapist (ST), the ST stated Resident 41 had a fall and was not eating after returning from the hospital . The ST stated she was asked to evaluate Resident 41 swallowing . The ST stated she recommended a downgrade to pureed diet. The ST stated Resident 41 had weight loss. During an interview on 7/24/25 at 4:16 p.m. with the Administered in Training (AIT), the AIT stated Resident 41's weight loss should have been discussed in the IDT meeting on 3/1/25. The AIT stated the RD should have implemented interventions to prevent further weight loss. The AIT stated he was not notified of the weight loss on 6/2025 and 7/2025. The AIT stated he was not part of the IDT meeting. The AIT stated the weight loss should have been discussed during stand up (a short, daily meeting where team members quickly update each other on their progress and any roadblocks they're facing). The AIT stated all team members including himself should have been notified of the weight loss. The AIT stated it was important to notify all team members so residents would not have further weight loss. The AIT stated the weight loss could have contributed to residents eating less, eventually declining and dying.During an interview on 7/24/25 at 5:30 p.m. with the Director of Nursing (DON) the DON stated she expected Resident 41's weight loss to be addressed. The DON stated the nurses should have contacted the physician[ and responsible party (R/P) right away about weight loss. The DON stated an IDT meeting with progress notes should have been done and there should have been documentation in the medical chart. The DON stated a change in condition (a noticeable alteration in a person's physical or mental state or in the circumstances surrounding a situation) should have been done. The DON stated the change of condition should be initiated on 3/1/25 with the first six pounds loss being identified. The DON stated the nurses should have documented the physician and R/P were notified on 6/1/25. The DON stated an IDT meeting should have been held on 3/2025 for the weight loss. The DON stated IDT should have been done weekly. The DON stated an IDT meeting was not done on time. The DON stated the IDT meeting should have been conducted on 6/14/25. The DON stated the physician should have been notified to recommend interventions to prevent further weight loss. The DON stated she should have monitored the intervention to see if it was effective. The DON stated the facility did not follow the weight management policy and procedure.During a review of Resident 41's Care plan Report undated, the Care Plan indicated, [box interventions/task] if weight decline persists, contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 8 of 31 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 07/24/2025 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 0692 Level of Harm - Actual harm Residents Affected - Few physician and dietician immediately.Determine percentage lost and follow facility protocol for weight loss.During a review of Resident 41's Skilled Nursing Nutrition Risk Review Form dated 3/5/25 the Skilled Nursing Nutrition Risk Review Form indicated, .admission weight185 lb.Most recent weight: 170 lb.Usual body weight (UBW): 172-187 lb. There were no supplement recommendations and no documentation showing the physician and responsible party notification. During a review of Resident 41's Progress Note (PN) dated 6/12/25, the PN indicated, .Dietary: 6/1:160 lb, 5.3% 9 lb weight loss x 1 month (5/1/:169lb) and 10.6% 19 lb weight loss x 6 months (12/1: 179lb) . There were no supplement recommendations and no documentation showing the physician and responsible party notification.During a review of Resident 41's Progress Note (PN) dated 7/15/25, the PN indicated, .Dietary: 7/14:151lb, 2 lb weight loss x1 week (7/7:153lb) and significant 10.7% 18 lb weight loss x 2 months (5/1:169lb) .IDT recommendation: continue with plan of care and monitor weekly weight x 1 week. Add prostate 30 ml bid [twice a day ] . There was no documentation indicating the physician was notified. During a review of Resident 41's Progress Note (PN) dated 7/21/25, the PN indicated, New order received from MD [Name of MD] for Prostat 30ml BID for supplement. Called R/P [name of R/P] son to notify him of new order.During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, .Weights are monitor monthly and more often as recommended by the interdisciplinary care team.Intervention.g. Use of supplementation.During a review of the facility's policy and procedure (P&P) titled, Weight Management Policy dated 12/19/2022, the P&P indicated, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight.6.Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days). B. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions.During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, the article indicated, .Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both.During a review of a professional references titled Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016 , the article indicated, .The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight.During a review of a professional references retrieved from the Academy of Nutrition and Dietetics titled What Resources Are Available to Assist in Assessing Body Weight in Older Adults dated 7/1/2025 the article indicated, .Usual body weight (UBW), an individual's weight throughout adult life or a stable weight over time, is the preferred standard for older adults. Any recent weight changes, especially unintentional weight loss, would also need to be addressed in a care plan. UBW is considered more appropriate than desirable body weight or ideal body weight for weight-related interventions in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 9 of 31 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 07/24/2025 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 0692 older adults. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 10 of 31 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 07/24/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sample staff Licensed Vocational Nurse (LVN 2), when LVN 2 did not had the annual nursing skills training competency completed according to facility's policy and procedure (P&P) Nursing Skills Training and Competency Policy. This failure had the potential for areas of improvement to be identified for LVN 2 which placed all residents at risk for their health and safety.Findings:During an interview and record review on 7/24/2025 at 10:28 a.m. with the Director of Staff Development (DSD), the DSD stated LVN 2 did not have her annual nursing skills training competency check-off list in her personal file. The DSD stated it should have been done annually. The DSD stated it should have been done in 5/2025 and was not sure why it was not done. The DSD stated the annual nursing training skills training competency check-off list was needed to make sure the nurses were competent to care for the residents. The DSD stated the facility was currently working on getting the nursing skills competency check-off list for LVN 2. During an interview on 7/24/25 at 3:32 p.m. with the Director of Nursing (DON), the DON stated LVN 2 should have the nursing skills competency check off list evaluation during the first 90 days and then annually. The DON stated LVN 2's lack of competency could not have been identified, and the facility could not helped her improve on areas of concern. The DON stated LVN 2 could have benefit from the nursing skills competency evaluation check-off list. The DON stated resident care could effect by lack of competency check. The DON stated, We did not follow our policy and procedure.During a review of the facility's P&P titled, Nursing Skills Training and Competency Policy undated the P&P indicated, .Purpose: to establish standards for nursing skills and procedures in accordance with federal regulations, California Title 22, and evidence-based practices, ensuring the delivery of safe and high-quality care in a skilled nursing facility.Procedures and Guidelines.1.Competency Assessment.All nursing staff must demonstrate competency in required nursing skills upon hire and annually thereafter.skills competency will be assessed through a combination of hands-on demonstration, written evaluations, and direct observation. Event ID: Facility ID: 555115 If continuation sheet Page 11 of 31 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 07/24/2025 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to complete a performance review (a formal assessment of a nurse aide's job performance, covering areas like clinical competence, communication, teamwork, and professionalism, to identify strengths and areas for improvement) of every nurse aide at least once every 12 months for one of two sampled Certified Nursing Assistant (CNA 2) when CNA 2 did not receive nurse aide performance review every 12 months.This failure resulted in CNA 1 not getting their performance evaluated and had the potential for weak areas not to be identified and improved which could affect resident care. Findings: During a concurrent interview and record review on 7/24/25 at 10:02 a.m., with the Director of Staff Development (DSD), CNA2's personal file was reviewed. The DSD stated she was not able to find CNA 2's annual evaluation in her file. The DSD stated CNA 2 was hired on 5/1/24 and her annual evaluation should have been done 5/2025. The DSD stated she was the interim (temporary) DSD and was in a position to perform CNA 2's annual evaluation. The DSD stated the annual evaluation was important to identify the staff members' strengths and weaknesses. The DSD stated CNA 2's annual evaluation could have helped improved areas of concern by identifying areas of weakness which could have impacted residents' care. The DSD stated the annual evaluation could have increased staff morale when areas of strength were identified.During an interview on 7/24/25 at 3:32 p.m. with the Director of Nursing, the DON stated the annual evaluation should have been done by the DSD. The DON stated, staff should be getting annually evaluation for job performance and competency. The DON stated, We did not follow our policy and procedure.During a review of the facility's policy and procedures (P&P) titled, Certified Nursing Assistant Annual In-Services Training policy undated, the P&P indicated, .Policy Requirements: 1. Annual requirement: Each CNA must complete a minimum of 12 hours of in-service in training annually, based on their hire date or recertification renewal date . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 12 of 31 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 07/24/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and document review, the facility failed to have qualified, full-time oversite of Food and Nutrition Services. This deficient practice could result in compromising the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 55 residents who received food from the kitchen out of a census of 56. Findings: Review of the California Code, Health and Safety Code - HSC S 1265.4, a licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The requirements of subdivision (b) includes:(1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility.(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration.(3) A graduate of a dietetic assistant training program approved by the American Dietetic Association.(4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.(5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.(6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision.(7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).During an interview with the Dietary Supervisor (DS) on 7/21/25, DS stated she was the supervisor of the kitchen and started going to school to become a Certified Dietary Manager (CDM) in January 2025. DS stated she became the supervisor of the kitchen in December of 2024. DS stated the Registered Dietitian was at the facility one to two days a week. During an interview with the Dietary Supervisor Mentor (DSM) on 7/21/25 at 2:56 p.m., DSM stated he was a CDM at another facility and mentored DS. DSM stated his mentoring was usually by phone, not on site at the facility. During an interview on 7/22/25 at 2:19 p.m., RD stated she usually worked at the facility on Thursdays only.During an interview on 7/23/25 at 4:30 p.m., the Administrator in Training (AIT) stated he reviewed the Health and Safety Code, and the plan was to have DS qualified by becoming a CDM, and she was currently the CDM training. AIT stated he realized it would take a while for DS to complete the CDM training and confirmed she was not currently qualified to be the full-time person to supervise Food and Nutrition Services. AIT also stated DS had a CDM mentor (DSM), and there was an RD, but confirmed DSM and the RD did not work full time at the facility. Review of the undated job description titled Manager of Dining Services, provided as the job description for DS, showed the general (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 13 of 31 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 07/24/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm purpose of the position was to manage the operation of the Dietary Department to include staffing, food ordering and preparation, food delivery and clean-up in accordance with facility policies, physician orders, patient care plans, and appropriate regulations. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 14 of 31 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 07/24/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review the facility failed to ensure kitchen staff had the appropriate competencies to carry out the functions of the food and nutrition service when: 1. [NAME] 2 was not competent in the use of the dish machine and testing the dish machine sanitizer strength. 2. [NAME] 1 was not competent preparing pureed food. 3. [NAME] 1 and the Dietary Supervisor (DS) were not competent in the use of the three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing). These failures had the potential to result in contamination of resident food and utensils used by residents leading to illness for 55 who received food from the kitchen; This failure also had the potential for residents receiving a pureed diet to consume less food due to decreased palatability and appearance resulting food related medical complications for 8 residents on a physician prescribed pureed diet out of a census of 56. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:13 p.m. with [NAME] 2 and the Dietary Supervisor Mentor (DSM) in the kitchen, [NAME] 2, stated he was an ex-kitchen employee and currently worked in housekeeping but was helping out in the kitchen. As [NAME] 2 washed kitchen utensils in the dish machine, the temperature gauge for the dish machine was noted to be 110 degrees Fahrenheit (F-unit of measurement) for the wash cycle and the sanitizing cycle. [NAME] 2 stated the dish machine was a low-temperature dish machine (dish machine that uses chemical sanitizers instead of high heat to sanitize dishes). [NAME] 2 was asked to demonstrate checking the sanitizer strength in the dish machine. [NAME] 2 reached for Quaternary ammonium (Quat) test strips (used to measure the concentration of quaternary ammonium compounds in sanitizing solutions) to test water in the dish machine after the sanitizer cycle completed. [NAME] 2 was about to test the sanitizer in the dish machine with the Quat test strip, when the DSM stated the Quaternary ammonium test strips should not be used to test the sanitizer in the dish machine since chlorine was used as the sanitizer. The DSM handed [NAME] 2 chlorine test strips (used to measure the concentration of chlorine in a solution by using a chemical reaction that causes a color change on the strip). [NAME] 2 dipped the chlorine test strip in the solution inside the dish machine after the sanitizer cycle completed. [NAME] 2 compared the chlorine test strip to the color chart on the chlorine test strip vial. The strip did not change color. When the test strip was compared to the color chart located on the chlorine test strip container, the strip indicated a low concentration of less than 10 parts per million. (PPM - a way to express very dilute concentrations of substances, indicating how many parts of a substance are present in a million parts of the solution or mixture) [NAME] 2 stated the sanitizer strength was acceptable. DSM confirmed the test strip indicated there was no sanitizer in the dish machine. According to the test strip color chart, when the sanitizer is 50 PPM, the chlorine test strip will turn a light purple color. [NAME] 2 stated he did not know if there was a log to record temperatures or sanitizer strength for the dish machine. The dish machine manufacturer label, attached to the dish machine was observed. The manufacturer label indicated, .Minimum wash temperature: 120 F . Minimum chlorine: 50 PPM .During an interview on 7/21/25 at 3:25 p.m. with the DS, the DS stated the sanitizer strength should be checked before use, three times a day, when items were washed from the breakfast, lunch and dinner meals. The?DS also stated the temperature of the dish machine should be at 120 degrees F before use. The DS stated the dish machine needed to be run a few cycles before use to ensure the temperature reached 120 degrees F. DS also stated the dish machine log should be filled out for lunch before the dish machine was used at the lunch meal. During a review of the facility's document titled Dish machine Temperature Log (Low Temperature) dated July 2025, indicated boxes where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 15 of 31 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 07/24/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staff documented wash temperatures, and rinse chlorine ppm on a daily basis for breakfast, lunch, and dinner. All fields were filled out from July 1 to July 20, but for July 21, the lunch wash temperature and rinse ppm was not documented. During a concurrent interview and record review on 7/22/25 at 4:45 p.m. with the DS, the Dish Machine In-service Training, dated 12/19/24, was reviewed. The Dish Machine In-service Training sign-in sheet indicated [NAME] 2 was not a participant in the training, and the DS confirmed [NAME] 2 was not a participant. The DS stated she was not able to provide dish machine in-service training for [NAME] 2. During a review of the facility's policy and procedure (P&P) titled, Dishwashing: Machine Operation, dated 2020, indicated, .All dishwashing machines should be operated according to manufacturer recommendations . If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function . If the machine is found to be out of the acceptable range for final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes .? 2. During a concurrent observation and interview on 7/24/25 at 10:59 a.m. with [NAME] 1 in the kitchen, [NAME] 1 was observed pureeing chicken for residents who received a pureed diet. [NAME] 1 added a brown colored liquid to the pureed cooked chicken in a blender and blended the ingredients. [NAME] 1 stated the brown colored liquid was chicken broth. [NAME] 1 blended the broth and the chicken. The consistency appeared to be runny. [NAME] 1 stated she added a total of three-and-a-half cups of chicken broth to the chicken because that was what the recipe stated to add. [NAME] 1 stated she would add more chicken broth if needed but did not think more chicken broth would need to be added. [NAME] 1 stated the pureed chicken should have a pudding-like consistency. [NAME] 1 stated she would check the consistency of the pureed chicken by doing a spoon test (a method to assess the consistency of a food item, particularly when it's being cooked or thickened, involving the use of a spoon to scoop up a sample and observing how it behaves, such as how it drips off the spoon, or whether it holds its shape). [NAME] 1 stated the pureed chicken should hold shape and not drip over the spoon. [NAME] 1 stated the consistency of the pureed chicken she just made was runnier. [NAME] 1 added one teaspoon (tsp) of thickener (a substance added to a liquid to increase its density, making it thicker), blended the pureed chicken, and added another tsp of thickener. Then added another tsp of thickener and blended. As [NAME] 1 prepared the pureed chicken, she referred to the recipe for Pureed Fried Chicken and stated she was following the recipe. During a review of Pureed Fried Chicken recipe, dated 2025, the recipe indicated, .To prepare 3 1/2 cups of chicken broth and to gradually add the broth as needed to prepared chicken and blend until smooth.Any liquid specified in the recipe is a suggested amount of liquid (if needed) . If product needs thinning, gradually add an appropriate amount of liquid to achieve a smooth, pudding or soft mashed potato consistency. During an interview on 7/24/25 at 11:05 a.m., with RD, the RD stated, according to the pureed fried chicken recipe, [NAME] 1 should not have added the entire three-and-a-half cups of chicken broth in order to get the desired consistency. During an interview on 7/24/25 at 11:51 a.m. with the RD, the RD stated small amounts of liquid should be added to achieve the desired consistency when pureeing food. The RD stated pureed foods should be a formed consistency, like mashed potatoes. RD stated she just did an in-service about how to puree foods with [NAME] 1 on 7/21/25. During a review of In-service Signature Sheet, dated 7/21/25, The In-service Signature Sheet indicated, .Subject: Fortified Diets . In-serviced on . proper procedure to puree . The In-service Signature Sheet indicated [NAME] 1 was in attendance. 3. During a concurrent observation and interview on 7/21/25 at 3:01 p.m. with [NAME] 1 and the DS in the kitchen, the three-compartment sink was observed. [NAME] 1 stated the three-compartment sink was used to wash kitchen utensils and other kitchen equipment if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 16 of 31 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 07/24/2025 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete dish machine was not working. [NAME] 1 described how to clean dishes in the 3-compartment sink. She stated the first sink was for washing, the second sink was for rinsing, and the third sink was for sanitizing. [NAME] 1 stated the third sink would be filled with a sanitizer solution. [NAME] 1 stated she did not know how long items had to be submerged in the sanitizing solution. [NAME] 1 stated she had to ask someone and walked away. When [NAME] 1 returned, she stated items had to be submerged solution in the third compartment should be 110 degrees F. [NAME] 1 stated she did not know what the temperature of the water in the wash and rinse compartments should be. The DS stated the instructions for use of the 3-compartment sink were posted above the sink and should be followed. The instructions titled [Brand Name] Pot & Pan Wash Procedure indicated to submerge items being cleaned in the sanitizer solution for one minute. The DS stated the instructions did not provide exact temperatures for the water and to rinse using hot water. The DS stated she thought the water in the wash compartment should be 110 degrees F. During an interview on 7/22/25 at 4:45 p.m. with the DS, the DS stated she was not able to provide documentation for training on the use of the three-compartment sink for any staff. During a review of the facility's P&P titled, Emergency Dishwashing, dated 2020, indicated, .Staff will follow emergency procedures established for dishwashing to comply with sanitation regulation at all times . The three-step manual washing process is as follows: First sink: 120 degrees F water and adequate detergent. Second sink: 120 degrees F clean, clear water. Third sink: Chemical sanitizing solution . Event ID: Facility ID: 555115 If continuation sheet Page 17 of 31 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 07/24/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure fortified (foods that have essential nutrients added to them, typically to improve their nutritional value or address nutrient deficiencies) diets were prepared according to facility fortified menu for 6 of 6 residents (Resident 2, 3, 18, 24, 26, and 56). This failure had the potential to result in weight loss and/or further complicate medical status for Resident 2, 3, 18, 24, 26, and 56 who received a prescribed fortified diet out of a of 56 residents. Findings: During a concurrent observation and interview on 7/21/25 at 12:08 p.m. with [NAME] 1 in the kitchen, the tray line food service (a food service model where trays are assembled in a linear fashion on a conveyor or table) was observed. [NAME] 1 plated food on resident plates, including a scoop of cooked cauliflower. [NAME] 1 reviewed Resident 1's meal ticket (a printed card or document that specifies a resident's diet order.?It includes details such as the resident's name, room number, diet type, allergies, and specific food and beverage requests). [NAME] 1 stated Resident 1's meal ticket called for a fortified diet. [NAME] 1 stated residents on a fortified diet received extra calories on their food. [NAME] 1 stated today extra butter was provided on the cauliflower for extra calories. When [NAME] 1 plated the meals for residents on a fortified diet (Resident 2, 3, 18, 24, 26, and 56) extra butter was not placed on the vegetables. [NAME] 1 explained when she prepared the cauliflower, she used more butter than what the recipe called for and she did not place an extra scoop of butter on the cauliflower when it placed on the plate. [NAME] 1 stated all residents received the same cauliflower, and there was no difference between the cauliflower served to a resident on a Regular diet and a fortified diet. During an interview on 7/21/25 at 12:50 p.m. with the Registered Dietitian (RD), the RD stated residents who had a fortified diet received extra calories by adding extra butter, dressing, or gravy to the food. The RD stated for lunch that day (7/21/25) fortified diets should have received extra gravy on the meat and butter on the vegetables. The RD stated the extra butter, and gravy had to be added on during tray line, not by adding extra butter during the cooking process, in order to ensure the correct portion of butter. During an interview on 7/22/25 at 2:19 p.m. with the RD, the RD stated staff had a menu to follow for fortified portions. During a concurrent interview and record review on 7/22/25 at 4:37 p.m. with the RD, the undated menu titled Fortified Diet Week 4 was reviewed. This menu indicated, Monday: Lunch: Ham: 1 oz (ounce) gravy. Vegetable: 1/2 oz melted margarine. The RD stated residents who had fortified diets were to receive 1 oz of extra gravy on the meat and 1/2 oz of extra butter on the vegetables for lunch on 7/21/25. The RD also provided the Weekly Guideline for Summer 2024 - Week 4, which showed the fortified diet provided an additional 300-400 calories and three (3) to four (4) grams of protein per day; and an undated document titled Fortified Diet which showed the fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The RD stated the goal was to increase the calorie density of foods commonly consumed by the residents. During a review of Resident 56's Order Summary Report (OSR), dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet . Start Date: 7/10/25. During a review of Resident 18's OSR, dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet . Start Date: 7/10/25. During a review of Resident 26's OSR, dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet . Start Date: 1/09/25. During a review of Resident 24's OSR, dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet . Start Date: 1/6/25. During a review of Resident 3's OSR, dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet . Start Date: 10/1/24. During a review of Resident 2's OSR, dated 7/23/25, the OSR indicated, Diet . Order Summary: Fortified diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 18 of 31 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 07/24/2025 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 0803 . Start Date: 6/13/25. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 19 of 31 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 07/24/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure foods were prepared by methods that conserve flavor, appearance, and at an appetizing temperature when: 1. The temperature of the ham, cauliflower, and sweet potato wedges served for the lunch meal was below 120 degrees Fahrenheit (F-unit of measurement) and barely felt warm in the mouth when sampled. 2. The pureed ham, cauliflower, and sweet potato wedges served for the lunch meal were a thin, runny consistency. 3. The pureed sweet potato wedges were bland. These failures had the potential to result in weight loss and/or further complicate medical status of residents for 55 residents who received food from the kitchen out of a census of 56. Findings:1.During a review of the facility's Diet Spreadsheet dated 2025, indicated, the lunch meals served on 7/21/25 included but was not limited to the following: Regular diet (a balanced, unrestricted meal plan that includes a variety of foods from all major food groups, suitable for individuals without specific dietary needs or restrictions): Honey Glazed Ham, Sweet Potato Wedges, Cauliflower; Pureed diet (a modified texture diet where food items are blended into a smooth, pudding-like consistency, eliminating any lumps): Pureed Honey Glazed Ham, Pureed Sweet Potato Wedges, Pureed Cauliflower. During a concurrent observation and interview on 7/21/25 at 12:46 p.m. with the Dietary Supervisor (DS) and the Registered Dietitian (RD), a regular diet and a pureed diet test tray (a method of evaluating the quality and safety of food served to residents) for lunch meal was observed. The temperature of the items on the regular diet test tray were measured with a calibrated thermometer and were as follows: ham: 109.3 degrees Fahrenheit (F); cauliflower: 108.4 degrees F; sweet potato wedges: 104.8 degrees F. The temperature of the items on the pureed test tray were ham: 100.6 degrees F; cauliflower: 101 degrees F; sweet potato wedges: 104 degrees F. The RD stated the temperature of the food when served to the residents should be at least 110 degrees F. The RD stated she did not conduct test trays and did not assess the food trays as they were delivered to residents. The RD stated she did not know the temperature of the food as it was delivered to residents. During a review of the Registered Dietician job description, dated 10/27/15, indicated, Evaluates . preparation of food service procedures . During a review of the facility's policy and procedure (P&P) titled, In-Room Dining, dated 2020, indicated, Meals served . may be periodically checked at the point of service for palatable food temperatures. Food temperatures of hot food on . trays at the point of service are preferred to be at 120 F or greater to promote palatability for the resident. 2. During an observation on 7/21/25 at 12:46 p.m. with the DS and the RD, a pureed diet test tray was observed. The pureed ham, cauliflower, and sweet potato wedges had a thin, runny consistency, and was spread out flat on the plate. During an interview on 7/24/25 at 11:51 a.m. with the RD, the RD stated the pureed food from the test tray was too thin. The RD stated the food should have been a mashed potato consistency. The RD stated if food was pureed too thin, residents could choke if they could not tolerate thinner liquids. The RD also stated if the pureed food was thin, it may not have an appealing feel/texture in the mouth and residents could be sensitive to mouth textures. The RD stated the liquid/thin appearance of the pureed food was not appealing and may cause residents to eat less. During a review of the facility's document Long Term Care Diet Manual dated 2022, indicated the pureed diet was for individuals who were not able to chew foods and/or have difficulty swallowing. The appropriate consistency included consistency such as puddings and smooth mashed potato. 3. During an observation on 7/21/25 at 12:46 p.m. with the RD, a Regular and Pureed diet test tray was observed. When the regular sweet potatoes were tasted, they were flavorful, but when the pureed sweet potatoes were tasted, the flavor was bland (with little flavor). The RD stated the pureed sweet potatoes tasted bland. During a concurrent interview and record review on 7/21/25 at 1:02 p.m. with [NAME] Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 20 of 31 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 07/24/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 1, [NAME] 1 stated she did not follow a recipe for sweet potatoes because the sweet potatoes came prepared in a box. [NAME] 1 stated she added milk and thickener (a substance added to a liquid to make it thicker and more resistant to flowing) but no extra seasoning when she pureed the sweet potato wedges for the lunch meal. Review of the Pureed Sweet Potato Wedges recipe dated 2025, indicated, . Add hot milk as needed when the product needs thinning to achieve the desired consistency. [NAME] 1 stated she did not taste the sweet potatoes before they were served to residents. During an interview on 7/22/25 at 11:51 a.m. with the RD, the RD stated cooks should be following recipes when meals were prepared for residents. The RD stated cooks should taste the food. The RD stated salt should not be added to recipes, but it was acceptable to add other seasonings/spices in order to increase flavor. During an interview on 7/24/25 at 3:30 p.m. with the RD, the RD stated the lack of flavor of the pureed food may result in residents eating less. During a review of Cook job description, dated 9/1/16, indicated, .Follow recipes and prepare foods that correspond to menu cycles . [NAME] or prepare palatable . meals . During a review of the facility's P&P titled, Pureed Food Preparation, dated 2020, the Pureed Food Preparation indicated, Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability . The recipes will be adjusted . indicating seasoning and technique to ensure the highest quality . the flavor of pureed foods will be assessed. The pureed food should have the same desirable flavor as the menu item. Event ID: Facility ID: 555115 If continuation sheet Page 21 of 31 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 07/24/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' preferences were honored for one of 19 sampled residents (Resident 20) when, Resident 20's meal card (printed ticket or document associated with each resident that details their specific dietary needs, preferences, allergies, adaptive equipment requirements, and even dislikes, ensuring personalized meal delivery and safety) did not have anything listed on his dislikes and the meal card was not updated to include his dislikes for fishes.This failure resulted in Resident 20 feeling unheard when served disliked food and had the potential for weight loss from not eating.Findings:During a concurrent observation and interview on 7/21/25 at 12:20 p.m., in the dining room, Resident 20 ‘s meal card did not have anything listed on his dislikes. Resident 20 stated he did not like fish and was served fish in the facility. Resident 20 stated he had been in the facility for one year and his meal card was not updated to reflect his dislikes. Resident 20 stated staff did not listen to him. During an interview on 7/23/2025 at 4:18 p.m., with the Dietary Supervisor (DS), the DS stated she and the Registered Dietician (RD) were responsible for updating the resident's food preferences. The DS stated residents' likes and dislikes should have been on the meal card. The DS stated she was aware Resident 20 did not like fish. The DS stated she should have updated the food preferences for Resident 20. The DS stated Resident could have been served fish when it was not listed on his food preferences. The DS stated Resident 20 could get upset and not have eaten his meals which could have caused weight loss.During an interview on 7/23/2025 at 4:40 p.m., with the RD, the RD stated she expected the meal card to be updated quarterly (3 months) and as needed. The RD stated residents' food preferences should have been updated so likes and dislikes could have been identified. The RD stated if Residents were served food that they did not like, they would get upset and refuse to eat. The RD stated residents refusing to eat could have caused weight loss. The RD stated the kitchen staff should have been honoring the residents' food preferences. The RD stated, We did not follow our policy and procedure.During a review of Resident 20 s admission Record (document containing resident demographic information and medical diagnosis) dated 7/24/25, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses of muscle wasting (decrease in muscle mass and strength, often due to inactivity, disease, or aging), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), bipolar disease (have mood swings that range from the lows of depression to elevated periods of emotional highs), dysphagia (difficulty swallowing), pain and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity. During a review of Resident 20 Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/11/25, the MDS, indicated Resident 20's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 20 was cognitively intact.During a review of Resident 20's Meal Card dated 7/21/25, the Meal Card indicated, no dislikes. During a review of the facility's policy and procedure (P&P) titled, Meal Identification, Resident Meal Card dated 2020, the P&P indicated, .All residents shall have a tray care on file indicating significant food preferences.Resident meal cards will include the residents.food preferences or dislikes.7.The Dining Service Manager will be responsible for ensuring that all resident meal care are up-to-date.9.d: food preferences are accurate and current. Event ID: Facility ID: 555115 If continuation sheet Page 22 of 31 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The dish machine was used without reaching 120 Fahrenheit (F-Unit of measurement) and without sanitizer. 2. The ice machine was not clean and was not cleaned according to the manufacturer's instructions. 3. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation and was not clean. 4. Kitchen floors, ceiling panels, walls, doors, and screens were not maintained in good condition. 5. The area underneath the three-compartment sink was not clean. 6. A can-opener and serving trays were not clean. 7. Pastrami deli meat and canned mushrooms were not discarded by the used by date (indicating the last day the product is recommended for use). These failures had the potential to contaminate resident food sources that can cause foodborne illness in a vulnerable population, resulting in severe patient harm, and even death. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:13 p.m. with [NAME] 2 and the Dietary Supervisor Mentor (DSM) in the kitchen, [NAME] 2 was washing kitchen utensils in the dish machine. The temperature gauge for the dish machine was noted to be 110 degrees Fahrenheit (F) for the wash cycle and the sanitizing cycle, while the dish machine was operating. [NAME] 2 stated the dish machine was a low-temperature dish machine (dish machine that uses chemical sanitizers instead of high heat to sanitize dishes). [NAME] 2 stated the dish machine was used to clean utensils and other kitchen equipment. [NAME] 2 tested the sanitizer strength in the dish machine by dipping a chlorine test strip (used to measure the concentration of chlorine in a solution by using a chemical reaction that causes a color change on the strip) in the dish machine water after the cycle was completed. The chlorine test strip did not change color. The DSM, who was a mentor for the Dietary Supervisor (DS), dipped a new chlorine test strip in the water. The chlorine test strip did not change color. The DSM stated the tubing for the sanitizer that supplied the dish machine with sanitizer was pinched and confirmed the sanitizer was not reaching the dish machine while [NAME] 2 was using the machine to clean kitchen utensils. [NAME] 2 confirmed he did not check the sanitizer strength before he started using the dish machine. During an observation on 7/22/25 at 11:29 a.m. in the kitchen, the dish machine manufacturer label, attached to the dish machine, was observed. The manufacturer label indicated, Minimum wash temperature: 120 F . Minimum chlorine: 50 PPM (parts per million - measurement used to express very small concentrations of a substance within a larger mixture or solution). During an interview on 7/22/25 at 3:25 p.m. with the DS, the DS stated the sanitizer strength should be checked before use, three times a day, when items were washed from the breakfast, lunch and dinner meals. The DS also stated the temperature of the dish machine should be at 120 degrees F before use. The DS stated the dish machine needed to be run a few cycles before use to ensure the temperature reached 120 degrees F. During a review of the facility's P&P titled, Dishwashing: Machine Operation, dated 2020, indicated, .All dishwashing machines should be operated according to manufacturer recommendations . If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function . If the machine is found to be out of the acceptable range for wither final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes . 2. During a concurrent observation and interview on 7/22/25 at 11:40 a.m. with the Maintenance Supervisor (MS) in the kitchen, the MS opened the ice machine to observe the interior components. The ice machine had yellow residue along the length of the upper part of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 23 of 31 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many plastic frame of the evaporator plate (the surface within an ice machine where water freezes into ice). A white napkin was used to wipe the yellow residue which came off on to the napkin. In addition, there was a rough texture along the upper part of the evaporator plate frame. The MS stated the ice machine was cleaned monthly. The MS stated he followed instructions for cleaning the ice machine from the manufacturer. During and concurrent observation and interview on 7/22/25 at 2:10 p.m. with the MS in the kitchen, the MS provided instructions for cleaning the ice machine from the manufacturer. The MS provided two bottles of chemicals which he stated he used to clean the ice machine. One bottle was a nickel-safe cleaner (a cleaning solution specifically designed to remove scale and mineral buildup in ice machines and other equipment that have nickel or tin-plated components, without damaging sensitive parts) and the other bottle was sanitizer. The MS stated he ran the nickel-safe cleaner through the ice machine first, then the interior of the ice machine is sprayed with the nickel-safe cleaner. The MS stated the sanitizer was run through the ice machine after the nickel-safe cleaner. The MS stated the last step was to spray the nickel-safe cleaner again on the inside of the ice-machine and wipe down with a rag. During a concurrent interview and record review on 7/22/25 at 2:15 p.m. with the MS, the Cleaning Instructions - [Ice machine brand and model number] User Manual, (undated) was reviewed. The User Manual indicated, the sanitization step is the last step of the cleaning process for the ice machine. The MS confirmed he sprayed the nickel safe cleaner as the last step when cleaning the ice machine. When the instructions were reviewed, MS confirmed sanitization was the last step of the cleaning process for the ice machine. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Surfaces of . equipment contacting food . such as . ice makers . must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Multiuse food-contact surfaces shall be smooth, and equipment food-contact surfaces are to be clean to sight and touch and shall be sanitized before use and after cleaning.During a review of the facility's P&P titled, Cleaning Instructions: Ice Machine and Equipment, dated 2020, indicated, Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures (if available) . 3. During a concurrent observation and interview on 7/21/25 at 10:08 a.m. with the DS and MS in the kitchen, the three-compartment sink was observed. Inside the third compartment of the three-compartment sink, there was pink residue around the rim of the drain opening. A white napkin was used to wipe the pink residue which came off on to the napkin and was slimy in texture. There was also a brownish-yellow film on the inside bottom and side surfaces of the sink. When wiped with a white napkin, the texture felt rough, and the brownish residue wiped off onto the napkin. In addition, there were what appeared to be gray colored (similar to the color of the metal sink), hard in texture patches, one inch in length, on an inside corner of the second and the third sink. These patches had rough edges and had brown and black residue on the surface. The MS stated the sink should be cleaned daily and should also be deep cleaned. During an interview on 7/21/25 at 2:56 p.m. with the DS, the DS stated that there was a cleaning schedule for the three-compartment sink. During an interview on 7/21/25 at 3:01 p.m. with [NAME] 1, [NAME] 1 confirmed she was responsible for cleaning the 3-comapartment sink and stated to clean the internal part of the three-compartment sink, she sprayed the inside of the sink down with water only and did not scrub the sink with a cleaner. During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated the three-compartment sink was used to wash produce. During a concurrent interview and record review on 7/23/25 at 9:25 a.m. with the DS, the Food and Nutrition: Cleaning Log . 3-compartment sink, dated 7/1/25 through 7/5/25 was reviewed. The DS stated according to the cleaning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 24 of 31 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many schedule, the three-compartment sink was cleaned twice a day, a.m. (morning) and p.m. (evening). The DS stated when [NAME] 1 was done with her shift, she cleaned the three-compartment sink. The DS said the evening shift should also be cleaning the three-compartment sink at the end of their shift. The DS stated if the three-compartment sink was being cleaned twice a day, there should be two staff signatures on the cleaning log corresponding with the 3-compartment sink. The DS stated she was responsible for reviewing the cleaning logs. The DS confirmed from July 1 to July 2025, the cleaning schedule did not show the cleaning for the 3-compartment sink was consistently completed twice a day. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .If a dish washing sink is used to wash produce, or thaw food, the sink shall be cleaned before and after each time it is used to wash produce or thaw food. Sinks used to wash or thaw food shall be sanitized before and after using the sink to wash produce or thaw food. During a review of the facility's P&P titled, Dishwashing: Manual, dated 2020, indicated, .Each compartment of the three-compartment pot and pan sink will be cleaned and sanitized before use. During a review of the Manager of Dining Services job description, (undated), the Manager of Dining Services job description indicated, .Ensure equipment and work areas are clean, safe and orderly . During a review of the facility's P&P titled, Sanitation of Dining and Food Service Areas, dated 2020, indicated, .The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department . All staff will be trained on the frequency of cleaning . A cleaning schedule will be posted for all cleaning tasks. Staff will initial the tasks as they are completed . Staff will be held responsible for all cleaning tasks. During a review of the facility's P&P titled, Sanitation, dated 2023, indicated, .The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . Each employee shall know how to . clean all equipment in his specific work area . The FNS Director will write the cleaning schedule in which he designates by job title and/ or the employee who is to do the cleaning task . the kitchen staff is responsible for all the cleaning . 4. During a concurrent observation and interview on 7/21/25 at 10:05 a.m. with the DS in the kitchen, the floor had cracks and broken tiles in areas throughout the kitchen. Also, areas where floor tiles were replaced there were gaps between the tiles with no grout which created an uneven surface. In addition, there were multiple areas throughout the kitchen where the baseboard or the transition strip between the baseboard and the wall was pulled away from the wall creating a gap. During an observation on 7/21/25 at 10:05 a.m. in the kitchen, gaps between the wall and drainpipes under the 3-comapartment sink and the dish washing sink were observed. During an observation on 7/21/25 at 12:16 p.m. in the kitchen, multiple ceiling panels throughout the kitchen were warped creating gaps in the ceiling cover. A ceiling panel containing a vent, located above the tray-line (food service assembly line where food items are placed on trays as they move along a conveyor or series of stations) area had black colored residue around the vent and around the perimeter of the panel. During a concurrent observation and interview on 7/22/25 at 11:42 a.m. with the MS in the kitchen, MS confirmed multiple ceiling panels were warped creating gaps. The MS stated the ceiling panel containing a vent had dust and debris. The MS stated the dust and debris on the ceiling panel was likely from the vent and was old debris. MS also confirmed there were multiple areas throughout the kitchen floor where there were cracked, broken, and uneven tiles, there were gaps in the baseboard and the wall, and there were gaps between the drainpipe sinks and the wall. During a concurrent observation and interview on 7/23/25 at 3:10 p.m. with the MS, a back door to the facility near the kitchen entrance was observed. The bottom portion of the door was cracked and had broken off chunks of wood. When the door was closed, the door did not fit snuggly so there were gaps between the door and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 25 of 31 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many door frame. Toward the top of the door there was a partially attached metal strip that created a gap in the door where the strip was pulled away. The MS stated that the door had a gap and needed to be repaired. During a concurrent observation and interview on 7/23/25 at 3:15 p.m. the back door in the kitchen was open with only the screen door closed. The screen in the screen door had multiple tears creating holes around the perimeter of the screen. The MS stated the screen had tears and needed to be patched. During a review of the Maintenance Director job description, dated 2/24/14, the Maintenance Director job description indicated, .Supervise the facility's day-to-day functions as it relates to the facility's interior . Ensuring that all maintenance activities in a facility are appropriately carried out. During a review of the facility's P&P titled, Cleaning Instructions: Ceilings and Walls, dated 2020, indicated, Ceilings and walls will be cleaned on a regular basis . Ceilings are cleaned annually, or as needed. During a review of the Federal Food Code, dated 2022, the Federal Food Code indicated, .Floors, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. In a food establishment in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed to no larger than 1 mm (millimeter). In addition, outer openings of a food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls, and ceilings. Doors are to be solid and tight fitting. If the doors are kept open for ventilation or other purposes, the openings shall be protected against the entry of insects and rodents by screens, properly designed and installed air curtains (a machine that blows a stream of air across and opening to create an air seal to the other side), or other effective means. 5. During a concurrent observation and interview on 7/21/15 at 10:08 a.m. with the DS in the kitchen, the floor under the three-compartment sink was observed to have yellow and brown residue on the surface, and there was a significant amount of gray-colored substance, resembling dust, on the surface of the pipes under the sink. In addition, an upright pipe under the sink was connected to the sink drainpipe and had a significant amount of thick yellowish build-up on the inner surface of the pipe. The DS stated the area under the three-compartment sink looked old. The DS stated there was residue on the floor under the three-compartment sink. The DS stated the debris hanging from the pipe was fuzzy stuff. The DS stated the floors were swept and mopped by staff twice a day, including under the three-compartment sink. During a concurrent observation and interview on 7/21/25 at 10:13 a.m. with the Maintenance Supervisor (MS) in the kitchen, the floor under the three-compartment sink was observed. The MS stated the floor under the three-compartment sink was dirty. MS also stated he thought the thick yellow build-up in the upright pipe was grease. The MS stated, The place has been a mess. According to the 2022 Federal Food Code, physical facilities shall be cleaned as often as necessary to keep them clean. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, the presence of food debris or dirt on nonfood contact surfaces can provide a harborage for insects and other pests. During a review of the facility's P&P titled, Cleaning Instructions: Floors, dated 2020, indicated, .Guideline: Floors will be kept clean and sanitary, washed daily or as needed. 6 a. During a concurrent observation and interview on 7/21/25 at 9:58 a.m. with the DS in the kitchen, an industrial can opener held in a base attached to a food preparation table was observed. The can opener blade was observed to have a sticky gray colored residue. The can opener base was observed to have brown and black colored residue on the surface and imbedded around the perimeter crevices where the base came into contact with the table. The DS stated the can opener blade had a sticky gray residue. The DS stated the base of the can opener was not clean. The DS stated the can opener should be cleaned by staff after each use. The DS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 26 of 31 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 07/24/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete stated the can opener was used to open cans containing food. During a review of the facility's P&P titled, Cleaning Instructions: Can Opener, dated 2020, indicated, .Protocol for counter-mounted can openers: Pay close attention to blade . Wash the base carefully with mild detergent and hot water; be sure to get rid of all food particles from the blade and base. During a review of the facility's P&P titled Sanitation dated 2023, showed .All . equipment shall be kept clean . 6 b. During a concurrent observation and interview on 7/21/25 at 11:47 a.m. with the Registered Dietitian (RD) in the kitchen, plastic serving trays used to carry such things as residents' meal plates, napkins, utensils, and drinks were observed. The plastic trays had black, pink, and brown discoloration on the surface. The RD stated the trays were not clean. During a review of the facility's P&P titled, Sanitation, dated 2023, indicated, .All . utensils and equipment shall be kept clean . Plastic ware . that becomes unsightly, unsanitary . shall be discarded. During a review of the facility's P&P titled, Storing Utensils, Tableware, and Equipment, dated 2020, indicated, .Clean and sanitize trays . used to carry clean tableware and utensils. Do this daily or as often as necessary. 7. During an observation on 7/21/25 at 9:30 a.m. in the walk-in refrigerator, a package of open deli meat in a metal container was observed. The package indicated, Contents: Sliced Pastrami; O (opened): 6/23/25; UB (use by): 7/16/25. During an observation on 7/21/25 at 9:30 a.m. in the walk-in refrigerator, mushrooms in a plastic, re-usable container were observed. The label on the plastic container indicated, Item: Mushrooms; Prep Date: 7/12/25; Use By: 7/18/25. During a concurrent observation and interview on 7/21/25 at 9:38 a.m. with the DS in the walk-in refrigerator, the deli meat and mushrooms were observed. The DS stated the deli meat was Pastrami deli meat. The DS stated the mushrooms in the plastic container were canned mushrooms. The DS stated food items stored in the walk-in refrigerator were dated after opening and discarded within three days. The DS stated there was a binder for staff to reference food discard dates. The DS stated all staff were responsible for discarding food items. The DS stated staff should be checking the use by dates on food items and discarding them as needed. The DS stated the deli meat and mushrooms should be discarded because they were past the use-by date. During a review of Cupboard Storage Chart, (undated), the Cupboard Storage Chart indicated, Cured and Smoked Meats: . lunch meats, opened . Refrigerator at 32 to 40 F (Fahrenheit) . 3 to 5 days. The Cupboard Storage Chart indicated, Canned and Dried Foods: . opened vegetables . Storage: 2 days. During a review of the facility's policy and procedure (P&P) titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, indicated, General storage guidelines to be followed . Discard food that has passed the expiration date . Event ID: Facility ID: 555115 If continuation sheet Page 27 of 31 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 07/24/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure arbitration agreements were explained to residents in a manner they could understand for 57 of 57 residents when the Admissions Coordinator (AC) did not explain arbitration to newly admitted residents.This failure violated the rights of 57 of 57 residents residing in the facility to be properly informed of the arbitration process and agreement. During an interview on 7/23/25 at 10:54 a.m., with the AC, The AC stated she gave residents the arbitration agreement upon their admission to the facility. The AC stated she did not explain what arbitration was to any resident who were newly admitted . The AC stated she had residents review the agreement with the rest of the admission packet on their own time. The AC stated she did not know what arbitration was and therefore had never explained it to any resident.During an interview on 7/24/25 at 2:44 p.m. with the Administrator in Training (AIT), the AIT stated the AC needed to be familiar with what arbitration was and the facility's arbitration agreement. The AIT stated residents had the right to understand what arbitration was and to know their rights regarding the process. The AIT stated some residents may not want to sign the agreement if it was not thoroughly explained to them and it was also their right to be informed.During a review of the facility's policy and procedure (P&P) titled Arbitration, dated 12/19/22, the P&P indicated, .The facility asks residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility . When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care are, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including the language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 28 of 31 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 07/24/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to implement adequate measures and a comprehensive water management plan to minimize the risk of Legionella (a harmful bacterium that lives in water systems and areas that are continuously wet) and other pathogens in the building's water system.This failure had the potential to expose 57 of 57 residents to Legionnaires' disease (a disease caused by legionella which affects the lungs) or other opportunistic infections. Findings:During a concurrent interview and record review on 7/23/25 at 2:21 p.m., with the Maintenance Supervisor (MS) the Facilities, Water Management plan, undated, was reviewed. The Water Management plan's sections titled, Description of the Building Water System, Identification of Potential Growth Areas, and Control Measures and Monitoring, were all empty and incomplete. The MS stated no legionella testing was done in 2024, and the facility currently did not have its Water Management plan complete. The MS stated it was important to have a complete water management plan because proper measures and plans for legionella helped prevent residents from receiving harm if they were to be infected by the bacteria.During an interview on 7/23/25 at 4:08 p.m., with the Infection Preventionist (IP-healthcare professionals specializing in the surveillance, control, and prevention of infections), the IP stated the facility needed to have a complete legionella and water management plan in place. The IP stated Legionella was contagious and had the potential to infect everyone in the facility.During an interview on 7/24/25 at 2:44 p.m., with the Administrator in Training (AIT), the AIT stated the facility should have been aware the water management plan was incomplete. The AIT stated proper water management documentation should have been included in the Water Management binder.During an interview on 7/24/25 at 2:17 p.m., with the Director of Nursing (DON) the DON stated the facility's Water Management plan should have been complete. The DON stated it was important to have a complete the plan because it helped ensure legionella did not spread to the residents.During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, dated 7/2017, the P&P indicated . The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease. the water management program includes the following elements: . b. A detailed description and diagram of the water system in the facility. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . The identification of situations that can lead to Legionella growth . j. the documentation of the program . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 29 of 31 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 07/24/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when: 1. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation, did not drain, causing water and debris to back up into the sink. 2. The three-compartment sink was used as a food preparation sink and did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 3. The facility did not have drain plugs in order to plug the sinks of the three-compartment sink, so the sink could be used in the way it was intended for ware washing. These failures had the potential to contaminate food sources for 55 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death; this failure also had had the potential for inability to safely clean items such as food preparation equipment and food service utensils in the case the dish machine was not available for use for 55 residents who received food from the kitchen out of a census of 56. Findings: 1. During a concurrent observation and interview on 7/21/25 at 3:01 p.m. with [NAME] 1 and the Dietary Supervisor (DS) in the kitchen, the three-compartment sink was observed. [NAME] 1 stated the three-compartment sink was used to wash kitchen utensils and other kitchen equipment if the dish machine was not working. The DS stated the instructions for use of the 3-compartment sink were posted above the sink and should be followed. Review of the [Name Brand] Pot and Pan Wash Procedure dated 2011 posted on the wall above the three-compartment sink, showed procedures for use of the sink included: to fill the first sink (the wash sink) with water and solution, fill the second sink (the rinse sink) with hot water, and fill the third sink (sanitizer sink) with sanitizer solution. During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated in addition to having the sink available for washing dishes in an emergency, the three-compartment sink was used to wash produce. During a concurrent observation and interview on 7/24/25 at 3:30 p.m. with the Maintenance Supervisor (MS) in the kitchen, the first and third compartment of the three-compartment sink was filled with water. The second sink of the three-compartment sink was empty. The MS removed the drain plug from the first compartment and the water was slow to drain. The MS stated something was going on with the drains and the drains were bad. The MS removed the drain plug from the third compartment and water and black, and brown debris backed up into the second compartment. The MS stated the drain could not handle draining two compartments at the same time. The MS replaced the drain plug in the first compartment and left the third compartment unplugged to drain. The drain plug in the first compartment pooed out and water and debris backed up into the second and third compartment. According to the 2022 Federal Food Code, equipment shall be maintained in a state of repair, and a plumbing system shall be maintained in good repair. In addition, A plumbing system shall be installed to preclude backflow of . liquid . into the water supply system at each point of use . Improper plumbing installation or maintenance may result in potential health hazards such as . back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food contact surfaces. 2. During a concurrent observation and interview on 7/21/25 at 10:12 a.m. with the MS in the kitchen, the space under the three-compartment sink was observed. The drain leading from the three-compartment sink was plumbed directly into the wall and there was not an air gap in the drain. The MS confirmed there was no air gap under the three-compartment sink.?? During an interview on 7/23/25 at 8:46 a.m. with [NAME] 1, [NAME] 1 stated the three-compartment sink was used to wash produce as there was not a sink available for only food preparation. ? During a review of the Federal Food Code, dated 2022, Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 30 of 31 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 07/24/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete the food code indicate, .A direct connection may not exist between the sewage system and a drain originating form equipment in which food, portable equipment, or utensils are placed. ?? During a review of the facility's P&P titled, Accident Prevention - Safety Precautions, dated 2023, indicated, .Backflow Prevention/ Air Gaps: If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. An air gap is the most reliable backflow prevention device. It is the physical separation of the potable (drinking water) and non-potable (non-drinking water) water supply systems by an air space. All . food preparation sinks . shall be drained through and air gap into an open floor sink.? 3. During an interview on 07/24/2025 11:05 a.m., with DS, DS was asked to fill the sink compartments of the three-compartment sink with water to demonstrate the use of the sinks. DS stated the facility did not have drain plugs to plug the sinks so they could be filled. During a review of the facility procedure titled Dishwashing: Machine Operation dated 2020, indicated, if the dish machine was not functioning and cannot be repaired in a timely manner, the facility will use the manual dishwashing procedure. During a review of the facility procedure titled Dishwashing: Manual dated 2020, indicated all pots and pans shall be cleaned by washing, rinsing, and sanitizing, according to the following guidelines. These guidelines included but were not limited to: pots and pans will be washed in a hot detergent solution in the first compartment, rinsed in clean warm water in the second compartment, and sanitized by either heat or chemicals in the third compartment. The water in the first, second, or third compartment will be drained when it becomes heavily soiled. The sink will be refilled accordingly. Event ID: Facility ID: 555115 If continuation sheet Page 31 of 31