Health inspection·December 2, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, . Social worker consulted with [Registered Nurse] and escalated barriers for discharge to [skilled nursing facilities-SNF] to Leadership team. Statewide search for long term care placement at a SNF has been sent out and there are no acceptance. [Patient] came from home with daughter and per patient, is refusing to return due to not having support. During an interview on 12/2/25 at 10:49 a.m. with the administrator (ADM), the ADM stated Resident 1 was not readmitted into the facility since the court order to readmit Resident 1 was ordered on 11/7/25. The ADM stated the facility was informed by the acute care hospital (ACH), where Resident 1 was staying, that Resident 1 would be admitted to another facility. During an interview on 12/2/25 at 12:00 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process for an unplanned discharge was for the facility to involve the assistance of the social services director (SSD). LVN 1 stated it was the SSD who would arrange to call resident or resident representative to follow up on the unplanned discharge. During an interview on 12/2/25 at 12:38 p.m. with the SSD, the SSD stated the facility had informed him of the granted appeal that ordered the facility to readmit Resident 1. The SSD stated the facility initiated a plan to readmit Resident 1 by ensuring there was a room and bed available. The SSD stated there were multiple concerns regarding Resident 1 being readmitted to the facility. The SSD stated he was informed by the ADM that Resident 1 was being transferred to another facility. During an interview on 12/2/25 at 12:58 p.m. with the ADM, the ADM stated the facility was preparing to readmit Resident 1 when the court order was received. The ADM stated there were concerns with Resident 1's return to the facility due to Resident 1's history of behaviors. The ADM stated the SSD was assisting the ACH for an alternate placement for Resident 1. The ADM stated the facility was prepared to readmit Resident 1 ensuring there was a room available within the facility and initiated in-services for all staff on caring for residents with behaviors. The ADM stated the decision to not readmit Resident 1 was decided after concerns were raised with Resident 1's behavior. The ADM stated Resident 1 was not readmitted into the facility following the court order on 11/7/25. During a phone interview on 12/3/25 at 3:11 p.m. with Resident 1, Resident 1 stated he had been discharged from the ACH and was residing with a family member. Resident 1 stated he was informed that the facility was refusing to readmit him. Resident 1 stated his preference was to return to the facility as soon as possible. Resident 1 stated he was informed by the facility that they would not be re-admitting him following the court order on 11/7/25. During a review of Resident 1's hospital note titled, Emergency Department Note- Social worker Note, dated 11/17/25, the note indicated, . Patient accepted at [Facility Name] for long term care. family unable to care for patient. [Social worker] spoke with [Family Member] patient needs to be at a care facility, family unable to care for him. [Social worker] made patient aware that he has accepting placement, at first patient was upset, because he does not want to be at a care center, stated he would rather be on the street. Patient is bed bound, unable to ambulate due to functional status. Patient made aware being on the streets in his condition would be unsafe. Patient recently was home with [family member] and [family member] was unable to care for him. The Note indicated Resident 1 was discharged from the ACH to a skilled nursing facility on 11/17/25. During a review of document tilted, Notice of Transfer Discharge, dated 11/25/25, the document indicated, . [Resident 1] being discharged because the facility cannot safely or adequately meet your clinical, psychiatric, and behavioral health needs. On November 17, 2025, you were transferred from [ACH name] to your new residence, [Facility Name & Address] . During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, dated 12/19/22, the P&P indicated, . It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. Discharge refers to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555115 If continuation sheet Page 2 of 3 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 12/02/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.The facility's transfer discharge notice will be provided to the resident and the resident's representative in a language and manner they can understand. the notice must be provided at least 30 days prior to a facility initiated transfer or discharge of the resident. Exceptions to the 30-day requirement. the health and safety of individuals in the facility would be endangered due to clinical or behavioral status of the resident. in these exceptional cases, the notice must be provided to the resident. and long term care Ombudsman as soon as practicable before the transfer or discharge. emergency transfers/discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. the resident will be permitted to return to the facility upon discharge from the acute care setting. in situations where the facility has decided to discharge the resident while resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge. Event ID: Facility ID: 555115 If continuation sheet Page 3 of 3