Health inspection·October 30, 2025

F 0688 Level of Harm - Actual harm Residents Affected - Few left lower extremity. Physical Therapy to assist with ambulation (walking) and use of assistive devices. All splints (knee brace) must stay on until first post-op (postoperative - after a surgical procedure) appointmentFollow-up in [name of Orthopedic Physician] office in three weeks for wound check, suture/staple removal, and x-rays (medical imaging to create detailed images of bones, joints, and internal organs) of the operative extremity. During a review of Resident 1's Orthopedic Institute Progress Notes (OIPN), dated [DATE], the OIPN indicated, . Patient was lost to follow-up (did not see the Orthopedic Physician after the surgery) and had issues getting here from the skilled nursing facility (a healthcare center providing short-term rehabilitation or long-term care for individuals who need medical supervision and assistance with daily activities). Assessment/Plan: [name of Resident 1] with a history of a mechanical level fall (a fall caused by external forces, such as tripping over an obstacle, slipping on a wet surface, or stumbling) sustaining a left proximal third tibia fracture (a break in the upper portion of the left shinbone) post intramedullary nail on [DATE] lost to follow-up. patient has developed an equinus contracture as well as decreased ability to move her knee. Patient needs aggressive physical therapy as well as her range of motion. Knee immobilizer (a brace used to keep the knee joint stable and prevent movement after an injury or surgery) is discontinued. During a review of Resident 1's [name of rehabilitation facility] History and Physical (H&P), dated [DATE], the H&P indicated, .Impression: Weight-bear as tolerated left lower extremity, immobilizer at all times. During a concurrent interview and record review of Resident 1's [name of rehabilitation facility] Patient Transfer and Referral Record (PTRR), dated [DATE], with the Director of Nursing, the PTRR indicated, . Primary diagnosis (onset): GLF (ground level fall) L (left) tibial shaft fx (fracture) s/p IM nailing on [DATE]. The Medical Orders for Continued Care: was blank. The DON stated there were no instructions on the PTRR for The Medical Orders for Continued Care. During a concurrent interview and record review of Resident 1's Care Plan Reports (CPR), undated, with the DON, the CPR indicated there was no care plan to address Resident 1's knee brace and no orthopedic post-op follow up appointment was scheduled. The DON stated there were no care plans to address Resident 1's use of the knee brace and there was no orthopedic post-op appointment made for Resident 1. During a concurrent interview and record review on [DATE] at 1:16 p.m. with the Director of Rehabilitation Services (DOR), Resident 1's Physical Therapy Evaluation (PTE), dated [DATE] was reviewed. The PTE indicated, physical therapy (PT) was recommended 5 times a week for four weeks. The DOR stated during the course of Resident 1's physical therapy treatment, weight bearing was tolerated, standing balance was poor, and there was no progress. The DOR stated Resident 1 was self-limiting meaning that Resident 1 refused many of the therapy sessions, did not fully participate during the sessions due to pain and there was no progress. The DOR stated another PTE was completed on [DATE] and PT was recommended 5 times a week for four weeks. The DOR stated Resident 1's progress was slow and was not at her prior level of functioning. The DOR stated Resident 1 was wearing the knee brace during all the PT treatment sessions. The DOR stated there was no physician order to remove the knee brace and there should have been one. The DOR stated the PTE evaluations were based on the information provided from the previous rehabilitation facility during admission. During a concurrent interview and record review on [DATE] at 9:39 p.m. with Registered Nurse (RN) 1, Resident 1's AIE, dated [DATE] was reviewed. The AIE indicated, Resident 1 was admitted on [DATE] at 6:00 p.m. from [name of rehabilitation facility]. Resident 1 had Brace to left lower leg. RN 1 stated she admitted Resident 1 on [DATE] and recalled Resident 1 had a knee brace on her left leg. RN 1 stated during the admission assessment, an admission care plan was completed but a care plan for Resident 1's knee brace was not created or implemented. RN 1 stated she should have developed a care plan for the knee brace to provide the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 2 of 4 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 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Actual harm Residents Affected - Few care that was required. RN 1 stated she should have clarified the order for the knee brace with the physician for the use and frequency of the knee brace. RN 1 stated the knee brace was to immobilize the knee and to keep the knee aligned. RN 1 stated if the knee brace was on too long it can cause stiffness to a joint. RN 1 stated she was unaware Resident 1 was only supposed to keep the knee brace on for three weeks and should have seen the orthopedic specialist during this time. During an interview on [DATE] at 10:21 a.m. with [name of rehabilitation facility] Case Manager (CM), CM stated Resident 1 was admitted on [DATE] from [name of hospital] and discharged on [DATE] to the skilled nursing facility. CM stated the hospital's discharge instruction indicated Resident 1 was to wear the knee brace until the first post-op orthopedic appointment in 3 weeks and the patient or family was supposed to make the appointment. CM stated the rehabilitation facility did not ensure the follow up orthopedic appointment was made because Resident 1 was discharged before the three weeks. During an interview on [DATE] at 9:04 a.m. with the Attending Physician (AP) of the skilled nursing facility, the AP stated he saw Resident 1 on [DATE] during the admission assessment but was unable to recall a knee immobilizer on Resident 1. The AP stated the purpose of the knee brace was to prevent injuries to the knee and to keep the knee in alignment. The AP stated the long-term effect for continued use of the knee brace can cause stiffness to the knee, scar tissue to develop in the joint, and the injury will not heal. The AP stated staff need to obtain particular instructions from the transferring facility to provide the required care Resident 1 needed. The AP stated facilities need to communicate the progress of Resident 1's physical therapy and have a plan to provide the care. The AP stated staff should have contacted him to obtain instructions on use of the knee brace. The AP stated he would have instructed staff to contact the orthopedic specialist for those instructions. The AP stated it was standard of practice to follow the specialist's recommendation after an orthopedic procedure. During an interview on [DATE] at 10:04 a.m. with the DOR, The DOR stated the rehabilitation department did not require or request additional information from the transferring facility because it was a nursing responsibility. The DOR stated there was enough information to evaluate Resident 1 and to recommend a PT plan. The DOR stated range of motion exercises was provided during the therapy sessions, but Resident 1 was self-limiting which did not advance her ability. The DOR stated the purpose of the knee brace was to remind staff and the patient not to move the knee and provide stability to the knee. The DOR stated long term use of the knee brace can have negative effects on the knee causing joint stiffness. During an interview on [DATE] at 11:25 a.m. with the Director of Nursing (DON), the DON stated the purpose of the knee brace was to provide stability after surgery and long-term effects of keeping the brace on which can cause stiffness to the joint. The DON stated it was standard of practice to contact the physician for the use of the knee brace to develop a resident centered care plan to provide the range of motion service Resident 1 required. The DON stated the miscommunication of important information between the hospital, the rehabilitation facility and the skilled nursing facility contributed to the failure to address the use of Resident 1's knee brace and failure to schedule a three-week post-op appointment for Resident 1 was unacceptable. During an interview on [DATE] at 12:14 p.m. with the Administrator (ADM), ADM stated the rehabilitation department assessed Resident 1 during the admission process, evaluated and recommended PT treatment. The ADM stated the discharge packet from the transferring rehabilitation facility did not address the use of the knee brace. The ADM stated it was nursing's responsibility to contact the physician, care plan the use of the knee brace, and share the information with the Interdisciplinary Team (IDT - a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of the resident). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 3 of 4 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 10/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Mountain Care Center 40131 Highway 49 Oakhurst, CA 93644 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The ADM stated each department had a scope of practice, PT determines immobilization, nursing coordinates all care areas as an IDT and develop care plans, and the physician oversees the care of residents and write orders. The ADM stated the miscommunication of important information between the hospital, the rehabilitation facility and the skilled nursing facility contributed to the failure to address the use of Resident 1's knee brace and failure to schedule a three-week post-op appointment for Resident 1 was unacceptable. During an interview on [DATE] at 5:44 p.m. with the Orthopedic Physician (OP), the OP stated she did not see Resident 1 until [DATE]. The OP stated a general two-to-three-week post-op appointment was required to assess the wound and to remove the knee brace or immobilizer at the first appointment. The OP stated there was a break at the top of Resident 1's knee joint and an incision was made around knee joint to insert a rod to stabilize the tibia. The OP stated the purpose of the knee brace was to help with the acute swelling phase (the initial stage of the body's response to an injury or infection, typically lasting two to four days), to prevent bending of the joints, and should be removed two to three weeks post-op and start physical therapy with range of motion exercises. The OP stated when she saw Resident 1 on [DATE] Resident 1 had developed significant scar tissues to the left ankle called an equinus contracture to where Resident 1 would not allow the OP to touch because of the pain. The OP stated the transferring facility and receiving facility missed opportunities to communicate important information for the care of Resident 1. The OP stated the receiving physical therapy department could have reached out and update the OP of the progress of Resident 1. The OP stated she would have brought Resident 1 in sooner to assess and make recommendations. The OP stated it was not acceptable to leave the knee brace on for two and a half months without orthopedic follow up. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated [DATE], the P&P indicated, .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. During a professional reference review retrieved from https://newwestsportsmedicine.com/wp-content/uploads/2023/07/tibial-nail-surgery-rehab-protocol.pdf titled, Tibial Nail Surgery Rehab Protocol, retrieved on [DATE], the professional reference indicated, 0?2 weeks: Non?weightbearing or toe?touch weightbearing (a partial weight-bearing restriction where only the toes of the injured or operated leg can lightly touch the ground for balance, while the majority of the body's weight is supported by an assistive device like crutches) on operative leg. Postop splint (knee brace) in place. Encourage knee and hip ROM (range of motion). 2?4 weeks: Non?weightbearing or toe?touch weightbearing on operative leg. CAM boot (Controlled Ankle Motion - a type of walking boot or orthopedic boot used to immobilize and protect the foot and ankle after an injury or surgery) to be worn except with exercises or showering. ROM home exercises. 4?6 weeks: Non?weightbearing on operative leg. CAM boot to be worn except with exercises or showering. Ankle and knee ROM encouraged. Gentle non?weightbearing strengthening exercises may start at 4 weeks if ROM regained. PT starts 2?3/week for 6?8 weeks. 6?12 Weeks: WBAT (weight bearing as tolerated) in CAM boot starting at 6 weeks for most fractures. Strengthening, proprioception (the body's ability to sense its position, movement, and orientation in space through stimuli originating from within the body itself), quadriceps (large front thigh muscle) strengthening. Continue PT 2?3/weeks. 12+ Weeks: Typically wean out of CAM boot. Continue strengthening exercises as needed. Formal PT depends on patient progress. Event ID: Facility ID: 555115 If continuation sheet Page 4 of 4