Health inspection·September 12, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated that after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in the hallway. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 2 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. The DON stated all nurses in the facility should have followed the process for documenting including the full completion of Resident 1's SBAR and progress note. The DON stated the nurses had been educated on the importance of complete and accurate documentation in the facility.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area, had now exacerbated since the fall. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated that prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated that his pain level decreased to 6/10 with pain medication since the fall. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request.During a review of Resident 1's, Order Summary Report, dated 8/15/25, the report indicated, . Oxycodone oral solution. give 15 ml (unit of measure) every 4 hours as needed for pain. During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary (IDT) team regarding the resident's condition and response to care. the following information is to be documented in the resident medical record, objective observations. treatments or services performed, changes in the residents condition, events, incidents or accidents involving the resident. documentation in the medical record will be objective, not opinionated or speculative, complete and accurate. documentation of procedures and treatments will include care-specific details, including, the date and time the procedure/treatment was provided. the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated. Event ID: Facility ID: 555115 If continuation sheet Page 3 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident environment remained free from accident hazards and that residents received assistance devices to prevent accidents for one of seven sampled residents (Resident 1) when nursing staff were aware Certified Nursing Assistant (CNA)s used a regular wheelchair to transport Resident 1 over an elevated threshold (a strip of wood, metal, or stone forming the bottom of a doorway) to the smoking area, CNA 5 wheeled Resident 1's wheelchair pulling him backwards in order to get Resident 1 over the threshold and tilted, causing Resident 1 to fall back. Nursing staff did not evaluate the hazardous nature of the path of travel or the unsafe technique to tilt the wheelchair. Nursing staff did not consider a physical therapy evaluation for a new wheelchair with anti-tilt bars.These failures resulted in the unsafe practice of transporting Resident 1 which caused an avoidable accident on 7/25/25, Resident 1 struck the back of his head onto the concrete floor, suffering avoidable pain and injury to his neck.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the fire escape door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated the wheelchair went backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture. Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident1's, Situation, Background, Assessment and Recommendation (SBAR) Post Fall, dated 7/25/25, the SBAR indicated, . Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The documentation indicated Resident 1 fell in the hallway, but findings indicated Resident 1 experienced a fall going through the fire escape door.During a review of Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals (indicators that reflect a person's basic body functions and overall health), just wanted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 4 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 1's, SBAR Post Fall, dated 7/25/25, Progress Note (PN), dated 7/25/25 at 9:50 a.m., SBAR dated 7/25/25 and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, .Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The Radiology Result Report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. with LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in going through the fire escape door. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause of the fall and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain). The progress note indicated Resident 1 was reporting increased pain related to the fall on 7/25/25 and was not given the correct information regarding the x-ray results obtained.During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Progress Note, dated 7/25/25 at 9:50 a.m. and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . Prior to fall [Resident 1] was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology results report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to documentation. The DON stated she was not aware the x-ray results (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 5 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be excluded until the x-ray results were obtained for Resident 1.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain was located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury to his neck and back due to a medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., the therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs .During a concurrent telephone interview and record review on 9/11/25 at 1:15 p.m. with the director of rehab (DOR), Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., was reviewed. The therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs . The DOR stated Resident 1's recommended wheelchair was supposed to be used by Resident 1 beginning 7/25/25, but another resident in the facility was mistakenly sat on the wheelchair and it needed to be washed. The DOR stated the recommendation was given due to Resident 1 requesting a better wheelchair. The DOR stated that based on her visual assessment she did not like the way the previous original wheelchair looked and agreed to recommend a better wheelchair. When asked to elaborate on what constituted she did not like how the wheelchair looked, the DOR stated she . Just didn't like the way it looked . The DOR stated Resident 1 was not under her services, but it was something she observed and recommended a new wheelchair.During an interview on 9/12/25 at 10:42 a.m. with the administrator (ADM), the ADM stated Resident 1 had a fall on 7/25/25 when CNA 5 was backing him out through the fire escape door by his room. The ADM stated the general practice in the facility was not to tilt the wheelchairs. The ADM stated he was unaware if Resident 1's path to go outside had not been assessed for safety.During an interview on 9/12/25 at 11:17 a.m. with the DOR, the DOR stated that Resident 1's path was not assessed prior to the fall on 7/25/25 because it was a supervised path with staff having to push Resident 1 outside. The DOR stated, it was Resident 1's preference to utilize the fire escape door to enter and exit the facility when attending his smoke breaks. The DOR stated it was the staff taking Resident 1 outside, decision to determine if the wheelchair needed to be tilted or if they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 6 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few needed to pull Resident 1 backwards to get through the door. The DOR stated the fire escape door that Resident 1 was using, was not meant for daily access therefore it was not equipped to get Resident 1 outside safely. The DOR stated that ultimately if the staff member determined the safest way to get Resident 1 outside was to pull him backwards and tilt the wheelchair to keep him from falling, then that was the best way.During an interview on 9/12/25 at 11:23 a.m. with LVN 2, LVN 2 stated Resident 1 was being assisted outside by the staff on 7/25/25. LVN 2 stated the CNA 5 was pulling Resident 1 backwards going outside, once the threshold was passed, the concrete was slanted down. LVN 2 stated Resident 1's wheelchair wasn't tilted by the CNA 5 at the time of fall but rather the wheelchair tilted backwards during the path outside. LVN 2 stated the CNAs, and all staff members knew not to pull any residents into the facility backwards as LVN 2 had repeatedly informed the facility staff regarding this practice. LVN 2 stated Resident 1 had used that door every time he went outside and was not informed by anyone in the facility that the fire escape door could not be used.During a concurrent observation and interview on 9/12/25 at 12:07 p.m. with Resident 1, Resident 1's wheelchair located in Resident 1's room was observed, the wheelchair appeared new with anti-tilt bars located on the back of the wheelchair next to the wheels. Resident 1 stated staff would use the fire escape door before and at the time of the fall to take him outside for smoking breaks because it was wider and could fit his wheelchair without risk of injury. Resident 1 stated he was not pulled backwards all the time it was certain staff that would do that. Resident 1 stated he had requested a new wheelchair because the wheelchair that was given to him was not safe and would sometimes tilt, which he informed the facility staff of the issues. Resident 1 stated since the wheelchair was already tilting on its own, when the staff member took him outside on 7/25/25, the concrete going downhill caused the wheelchair to completely hit the ground backwards. Resident 1 stated the motion of pulling the wheelchair backwards could have caused the wheelchair to tilt backwards.During an interview on 9/12/25 at 1:20 p.m. with the minimum data set nurse (MDS), the MDS nurse stated Resident 1 had used the fire escape door when he was given a bigger wheelchair. The MDS nurse stated the facility made an exception to allow Resident 1 to use the fire escape door because it was a wider door for the wheelchair being used at the time of admission. The MDS nurse stated after Resident 1 received a new manual wheelchair that would fit through the designated resident door leading outside, Resident 1 continued to use the fire escape door. The MDS nurse stated the path leading outside was never assessed for safety.During an interview on 9/16/25 at 1:32 p.m. with the DON, the DON stated on 7/25/25 Resident 1 was being wheeled out by CNA 5 when he fell. The DON stated CNA 5 lost control of the wheelchair causing Resident 1 to fall going through the fire escape door. The DON stated the wheelchair itself was safer going backwards due to the risk of Resident 1's wheelchair bumping the threshold that would have caused him to go forward. The DON stated it was safer to use the designated resident door that all residents in the facility used because it had rails and the concrete wasn't made to go downward.During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, undated, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. a fall is defined as unintentionally coming to rest on the ground, floor or other lower level.During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 7 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 8 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents for one of five sampled residents, (Resident 1), when Resident 1 suffered a head and neck injury on 7/25/25, nursing staff did not assess Resident 1's pain, administer medications to effectively address the pain in accordance with professional standards of practice and the facility's policy and procedure Pain Management. On 7/25/25, staff tilted Resident 1's wheelchair backward in order to transport Resident 1 to the smoking area and Resident 1 fell backward, striking his head onto the concrete ground. Afterwards, Resident 1 complained of head and neck pain that radiated to the right side and nurses did not effectively treat the pain.These failures resulted in Resident 1 feeling unheard of, experiencing avoidable uncontrolled and unmanaged pain due to delay in assessment and treatment following the fall on 7/25/25.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status [BIMS screening tool used to assess resident cognitive (understanding through thought, experience and senses) level] score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the back door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated he fell backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor and offered to transfer him to the acute care hospital, but Resident 1 stated he refused. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture (break in a bone). Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated the radiology report was incomplete and after Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 9 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident 1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall Interdisciplinary team (IDT- consisting of nurses, physician, resident and other members of the health team to discuss and plan resident treatment plan), dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Order Summary Report, dated 7/26/25, the order summary indicated, Oxycodone-Acetaminophen/APAP (medication with high risk for addiction and dependence used to treat moderate to severe pain) tablet 10-325 mg . give 1 tablet every 8 hours as needed for pain for 30 days. discontinued date 8/11/25. The order summary indicated Resident 1 had an as needed pain medication available for 15 days following the fall on 7/25/25.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The note indicated Resident 1 had verbalized medication was not managing his pain effectively after the fall on 7/25/25.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a concurrent interview and record review on 8/29/25 at 10:33 a.m. with LVN 1, Resident 1's electronic medical record (EMR) for, Pain Levels, dated 7/26/25-8/25/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 10 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 1 stated the EMR for pain levels indicated Resident 1 complained of pain: 10/10 on 7/26/25 at 3:09 p.m. and 9/10 pain at 9:21 p.m. 9/10 p.m.7/28/25: 7:45 p.m. 10/10 pain, 7:45 p.m. 9/10 pain7/29/25: 1:31 p.m. & 9:06 p.m. 8/10 pain7/30/25: 12:45 a.m. 7/10 pain7/31/25: 9:57 a.m. & 3:00 p.m. 6/10 pain8/1/25: 2:22 p.m. 9/10 pain, 6:35 p.m. 10/10 pain8/4/25: 9:19 a.m. 9/10 pain8/7/25: 5:22 p.m. 9/10 pain8/8/25: 2:00 p.m. 9/10 pain, 5:31 p.m. 9/10 pain8/9/25: 11:55 a.m. 9/10 pain8/10/25: 11:03 p.m. 8/10 pain8/11/25: 6:05 p.m. 8/10 pain8/12/25: 9:54 a.m. 8/10 pain8/13/25: 3:36 a.m. 8/10 pain8/14/25: 9:13 a.m. & 3:00 p.m. 8/10 pain8/15/25: 10:19 a.m. & 2:32 p.m. 8/10 pain8/16/25: 10:01 a.m. & 4:15 p.m. 8/10 pain8/17/25: 10:12 p.m. 8/10 pain8/18/25: 10:57 p.m. 8/10 pain8/19/25: 8:28 a.m. & 12:54 p.m. & 5:05 p.m. & 11:15 p.m. 8/10 pain8/20/25: 8:02 a.m. & 4:03 p.m. 8/10 pain8/21/25: 12:42 p.m. & 4:43 p.m. 8/10 pain8/22/25: 6:05 a.m. 5/10 pain8/23/25: 4:08 p.m. 6/10 pain8/25/25: 12:05 a.m. 9/10 pain . LVN 1 stated Resident 1 pain levels averaged at an 8/10 pain based on the EMR pain levels reviewed. LVN 1 stated when Resident 1 complained of medication ineffectiveness and increased pain, it was the facility expectation that the nurse would complete an assessment to identify Resident 1's pain and severity, notify the physician and document. LVN 1 stated that based on the record review, Resident 1's pain was not effectively managed following the fall on 7/25/25.During a review of Resident 1's, Medication Administration Record (MAR), dated 7/2025 and 8/2025, the MAR indicated, . Oxycodone-Acetaminophen/APAP tablet 10-325 mg, administered:7/27/25: 3:47 p.m. Medication Effective No pain level.7/28/25: 7:45 p.m. Medication Ineffective pain level 9/10.7/29/25: 1:31 p.m. Medication Effective pain level 8/10.8/1/25: 2:22 p.m. Medication Effective pain level 9/10.8/2/25: 2:50 a.m. & 8:16 p.m. Medication Effective pain level 5/10.8/3/25: 12:10p.m. Medication Effective pain level 8/10.8/4/25: 1:19 a.m. Medication Effective pain level 7/10, 9:19 a.m. Effective pain level 9/10.8/5/25: 2:00 a.m. Medication Effective pain level 7/10.8/6/25: 5:59 a.m. Medication Effective pain level 7/10.8/7/25: 11:55 a.m. Medication Effective pain level 8/10.8/8/25: 8:43 a.m. Medication Effective pain level 9/10.8/9/25: 11:55 a.m. Medication Effective pain level 9/10.8/10/25: 9:57 p.m. Medication Effective pain level 7/10.8/11/25: 6:26 a.m. Medication Effective pain level 7/10, 3:20 p.m. Medication Unknown Effectiveness pain level 7/10. The MAR indicated Resident 1's pain medication was administered for pain and the follow up with the medication effectiveness was documented as medication was effective in managing Resident 1's pain even though Resident 1's pain levels reached 7/10-9/10.During a concurrent interview and record review on 8/29/25 at 11:12 a.m. with the DON, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The DON stated Resident 1's medication for pain was ineffective. The DON stated Resident 1's cervical x-ray had unknown results and therefore could not rule out an injury that could have caused Resident 1's increased pain. The DON stated the facility expectation was for the facility staff to inform the physician of findings regarding increased pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 11 of 12 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 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in order to achieve proper pain management for Resident 1 which was not done.During a concurrent interview and record review on 8/29/25 at 11:20 a.m. with LVN 2, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 2 stated, Resident had complained of 10/10 pain to his back during the day. LVN 2 stated Resident 1's pain levels ranged between 8-10/10 pain on a daily basis. LVN 2 stated the progress notes indicated Resident 1 was experiencing an increase in pain with unrelieved pain with medications ordered. LVN 2 stated the facility process was to complete an assessment of Resident 1, document in the EMR, and notify the physician of Resident 1's ineffective pain medication and increased pain. LVN 2 stated Resident 1's pain was not properly managed following the fall on 7/25/25.During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated, 9/2/22, the P&P indicated, . The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. the facility will Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon. a significant change in condition or status occurs. Manage or prevent pain, consistent with. current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident. Identifying key characteristics of the pain, Duration of pain, Frequency, Location, Timing, Pattern (e.g. constant or intermittent), Radiation of pain, Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms). The resident's goals for pain management and his/her satisfaction with the current level of pain control. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion . Event ID: Facility ID: 555115 If continuation sheet Page 12 of 12