Majestic Mountain Care Center

In the surveyor’s words

From the most serious findings on record at Majestic Mountain Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 7, 2024

  Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) to staff and residents. Specifically, the facility failed to: 1. Ensure timely COVID-19 testing of symptomatic staff and residents and the implementation of COVID-19 testing during an outbreak, 2. Ensure staff were wearing proper Personal Protective Equipment (PPE), 3. Ensure signage was posted of proper PPE for rooms with positive COVID-19 residents, and 4. Ensure staff were fit tested for N-95 respirator masks. The failed practices had the potential to affect all residents that resided in the facility. […]

• Immediate jeopardy, patternF686Aug 7, 2024

  Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents with pressure ulcers received treatment and services in accordance with professional standards of practice, to promote healing and prevent deterioration for 3 (Residents #15, #5, and #46) of 3 sampled residents reviewed for pressure ulcers. Specifically, the facility failed to: - Accurately and consistently assess and document the appearance, stage, and complete measurements of pressure ulcers at least weekly to facilitate the ability to promptly identify deterioration or track healing progress of pressure ulcers for Residents #15, #46, and #5. […]

• Actual harm, isolatedF688Oct 30, 2025

  Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to increase range of motion (the full movement potential of a joint to flex and extend in any direction) to prevent further decrease in range of motion for one of four sampled residents (Resident 1) when Resident 1 had left knee surgery on [DATE] and a knee brace (a medical device worn on the knee to support, correct, or protect the joint for functional improvement) was left on Resident 1's left leg continuously until [DATE]. […]

• Actual harm, isolatedF689Sep 12, 2025

  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. […]

• Actual harm, isolatedF697Sep 12, 2025

  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. […]