Map showing the location of MAJESTIC MOUNTAIN CARE CENTER in OAKHURST, California
40131 HIGHWAY 49, OAKHURST, CA, 93644

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaLowest tier among peers1,154 rated homes · average 3.2★
  • Madera CountyLowest tier among peers5 rated homes · average 2.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs CA avg
  • StaffingCan add or remove a star1★−2.1 vs CA avg
  • Quality measuresCan add or remove a star3★−1.1 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 9% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.42hrsAbove only 3% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.33hrsAbove only 19% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better63%Above only 3% of peersCA avg38%RN turnover67%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$252,683Above only 1% of peersCA avg$26,970Fines · denials2 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
59citations
17inspection dates
4actual harm (G–I)
2immediate jeopardy (J–L)
Dec 2, 2025most recent

Citations by monthAug 2019 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 2, 20251 citationCycle 1worst D · no actual harm
  1. F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident RightsD · isolatedCorrection pending
Oct 30, 20251 citationCycle 1worst G · actual harm
  1. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareG · isolatedCorrected Dec 2, 2025
Sep 12, 20253 citationsCycle 1worst G · actual harm
  1. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Dec 2, 2025
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 7, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Oct 7, 2025
Jul 24, 202514 citationsCycle 1worst G · actual harm$160,666, payment denial
  1. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Oct 30, 2025
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 30, 2025
  3. F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.AdministrationF · widespreadCorrected Oct 30, 2025
  4. F908Keep all essential equipment working safely.EnvironmentalF · widespreadCorrected Oct 30, 2025
  5. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Oct 30, 2025
  6. F584Honor 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.Resident RightsE · patternCorrected Nov 13, 2025
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Oct 30, 2025
  8. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Oct 30, 2025
  9. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Oct 30, 2025
  10. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Oct 30, 2025
  11. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected Oct 30, 2025
  12. F803Ensure 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.Nutrition and DietaryE · patternCorrected Oct 30, 2025
  13. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryF · widespreadCorrected Oct 30, 2025
  14. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Oct 30, 2025
Jun 5, 20252 citationsCycle 1worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 3, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 3, 2025
Feb 12, 20251 citationCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 7, 2025
Jan 30, 20252 citationsCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 20, 2025
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 20, 2025
Aug 15, 20241 citationCycle 2worst D · no actual harm$92,017, payment denial
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 14, 2024
Aug 7, 202413 citationsCycle 2worst L · immediate jeopardy$92,017, payment denial
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Aug 29, 2024
  2. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsF · widespreadCorrected Aug 29, 2024
  3. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Aug 29, 2024
  4. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsF · widespreadCorrected Aug 29, 2024
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Aug 29, 2024
  6. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Aug 29, 2024
  7. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Aug 29, 2024
  8. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningD · isolatedCorrected Aug 29, 2024
  9. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareK · patternCorrected Aug 29, 2024
  10. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 29, 2024
  11. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Aug 29, 2024
  12. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Aug 29, 2024
  13. F880Provide and implement an infection prevention and control program.Infection ControlL · widespreadCorrected Aug 29, 2024
May 15, 20241 citationCycle 2worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jul 22, 2024
May 6, 20241 citationCycle 2worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 17, 2024
Mar 1, 20242 citationsCycle 2worst D · no actual harm
  1. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Mar 25, 2024
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 25, 2024
Dec 29, 20231 citationCycle 3worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jan 26, 2024
Nov 13, 20233 citationsCycle 3worst D · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Nov 30, 2023
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 30, 2023
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 30, 2023
Aug 9, 20232 citationsCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Sep 1, 2023
  2. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Sep 1, 2023
Mar 23, 20231 citationCycle 3worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 11, 2023
Aug 30, 201910 citationsCycle 3worst F · no actual harm
  1. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Nov 22, 2019
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 22, 2019
  3. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 22, 2019
  4. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Nov 22, 2019
  5. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsF · widespreadCorrected Nov 22, 2019
  6. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Nov 22, 2019
  7. F584Honor 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.Resident RightsD · isolatedCorrected Nov 22, 2019
  8. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 22, 2019
  9. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Nov 22, 2019
  10. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceD · isolatedCorrected Nov 22, 2019

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.42hrsAbove only 3% of peers−1.09 vs CA avg
  • Registered nursesRN hours only0.33hrsAbove only 19% of peers−0.32 vs CA avg
  • Licensed practical nursesLPN hours1.01hrs
  • Nurse aidesCNA hours2.08hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.13hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better63%Above only 3% of peersCA avg 38%
  • RN turnoverRegistered nurses only67%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy66 certified beds · ~60 residents a day90%Above only 45% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $252,683In fines
  • 2Fines
  • 2Payment denials
  • $26,970CA avg in fines
Above only 1% of peersFewer fines than 1% of rated homes in California

Actions on record

  1. Jul 24, 2025Civil money penalty$160,666
  2. Jul 24, 2025Denial of payment for new admissionsfrom Aug 22, 2025
  3. Aug 7, 2024Civil money penalty$92,017
  4. Aug 7, 2024Denial of payment for new admissionsfrom Sep 6, 2024

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Bayshire Senior Communities12 facilities in the chain3.1★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Bayshire Central Valley LLC
Indirect owners (5%+)
  • Bayshire LLC
  • Benjamin Carter
  • Scott Kirby
  • Donald Salow
Corporate officers
  • Benjamin Carter
  • Scott Kirby
  • Donald Salow
Managing employees
  • Scott Kirby

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 555115 · 40131 HIGHWAY 49, OAKHURST, CA, 93644.
  • Percentiles compare this facility with every rated nursing home in California and Madera County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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