The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Majestic Mountain Care Center are:
F-0880 · August 7, 2024 · Grade L — Immediate jeopardy
Provide and implement an infection prevention and control program.
Status: Deficient, Provider has date of correction · correction date August 29, 2024
F-0686 · August 7, 2024 · Grade K — Immediate jeopardy
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Status: Deficient, Provider has date of correction · correction date August 29, 2024
F-0688 · October 30, 2025 · Grade G — Actual harm
Provide 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.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date December 2, 2025
F-0689 · September 12, 2025 · Grade G — Actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date October 7, 2025
F-0697 · September 12, 2025 · Grade G — Actual harm
Provide safe, appropriate pain management for a resident who requires such services.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date December 2, 2025
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Majestic Mountain Care Center, 17 subject areas appear across health and fire-safety inspections.
Infection prevention and control
5 citations between August 30, 2019 and July 24, 2025. The most serious was graded L — immediate jeopardy, affecting widespread across the facility. Surveyors found a situation that caused — or was likely to cause — serious injury, harm, impairment, or death, and that needed immediate correction. 2 of these citations came out of complaint investigations. Correction record: 5 citations show a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · August 7, 2024 · Grade L — Provide and implement an infection prevention and control program.
F-0880 · July 24, 2025 · Grade F — Provide and implement an infection prevention and control program.
F-0880 · August 30, 2019 · Grade F — Provide and implement an infection prevention and control program.
Quality of life and daily care
10 citations between March 1, 2024 and May 6, 2026. The most serious was graded K (immediate jeopardy). 7 of these citations came out of complaint investigations. Correction record: 10 citations show a recorded correction date.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0686 · August 7, 2024 · Grade K — Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F-0688 · October 30, 2025 · Grade G — Provide 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.
F-0689 · September 12, 2025 · Grade G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Fire, smoke, and emergency safety
18 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 18 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0345 · July 24, 2025 · Grade F — Have approved installation, maintenance and testing program for fire alarm systems.
K-0345 · August 7, 2024 · Grade F — Have approved installation, maintenance and testing program for fire alarm systems.
K-0347 · August 7, 2024 · Grade F — Properly provide smoke detection systems in areas open to corridors.
Resident rights
11 citations between August 30, 2019 and December 2, 2025. The most serious was graded F (potential for more than minimal harm). 3 of these citations came out of complaint investigations. Correction record: 11 citations show a recorded correction date.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0565 · August 7, 2024 · Grade F — Honor the resident's right to organize and participate in resident/family groups in the facility.
F-0585 · August 7, 2024 · Grade F — Honor 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.
F-0577 · August 30, 2019 · Grade F — Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Gas, Vacuum, and Electrical Systems
11 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 11 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0918 · July 24, 2025 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0926 · July 24, 2025 · Grade F — Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K-0918 · August 7, 2024 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
Fire, smoke, and emergency safety
10 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 10 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
E-0037 · July 24, 2025 · Grade F — Establish staff and initial training requirements.
E-0039 · July 24, 2025 · Grade F — Conduct testing and exercise requirements.
E-0006 · August 7, 2024 · Grade F — Conduct risk assessment and an All-Hazards approach.
Food, nutrition, and hydration
7 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 7 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0801 · July 24, 2025 · Grade F — Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F-0802 · July 24, 2025 · Grade F — Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F-0804 · July 24, 2025 · Grade F — Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Miscellaneous
3 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0712 · August 30, 2019 · Grade F — Have simulated fire drills held at unexpected times.
K-0711 · July 24, 2025 · Grade D — Provide a written emergency evacuation plan.
K-0741 · August 30, 2019 · Grade D — Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Physical environment and safety
2 citations between August 30, 2019 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0908 · July 24, 2025 · Grade F — Keep all essential equipment working safely.
F-0908 · August 30, 2019 · Grade D — Keep all essential equipment working safely.
Administration and leadership
1 citation between July 24, 2025 and July 24, 2025. The most serious was graded F (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Administrative citations suggest the problem sits with management systems, not one staff member. Ask who is responsible for quality oversight and what the home's own quality committee changed afterward.
F-0847 · July 24, 2025 · Grade F — Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Services
1 citation between August 30, 2019 and August 30, 2019. The most serious was graded F (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · August 30, 2019 · Grade F — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Nursing and Physician Services
3 citations between August 30, 2019 and July 24, 2025. The most serious was graded E (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
F-0726 · July 24, 2025 · Grade E — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F-0730 · July 24, 2025 · Grade D — Observe each nurse aide's job performance and give regular training.
F-0730 · August 30, 2019 · Grade D — Observe each nurse aide's job performance and give regular training.
Medication and pharmacy services
3 citations between August 30, 2019 and August 7, 2024. The most serious was graded E (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0756 · August 7, 2024 · Grade E — Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F-0759 · August 7, 2024 · Grade E — Ensure medication error rates are not 5 percent or greater.
F-0758 · August 30, 2019 · Grade D — Implement 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.
Egress
2 citations between August 30, 2019 and July 24, 2025. The most serious was graded E (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0293 · August 30, 2019 · Grade E — Have properly located and lighted "Exit" signs.
K-0293 · July 24, 2025 · Grade D — Have properly located and lighted "Exit" signs.
Assessments and care planning
14 citations between August 30, 2019 and January 28, 2026. The most serious was graded D (potential for more than minimal harm). 7 of these citations came out of complaint investigations. Correction record: 14 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0658 · January 28, 2026 · Grade D — Ensure services provided by the nursing facility meet professional standards of quality.
F-0658 · September 12, 2025 · Grade D — Ensure services provided by the nursing facility meet professional standards of quality.
F-0658 · June 5, 2025 · Grade D — Ensure services provided by the nursing facility meet professional standards of quality.
Freedom from abuse, neglect, and exploitation
5 citations between May 6, 2024 and March 24, 2026. The most serious was graded D (potential for more than minimal harm). 5 of these citations came out of complaint investigations. Correction record: 5 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0600 · March 24, 2026 · Grade D — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0609 · March 24, 2026 · Grade D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F-0609 · February 12, 2025 · Grade D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Construction
1 citation between August 30, 2019 and August 30, 2019. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0161 · August 30, 2019 · Grade D — Use approved construction type or materials.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Majestic Mountain Care Center appears in CMS data on 22 survey dates between August 30, 2019 and May 6, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
May 6, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 28, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
March 24, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
January 28, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
December 2, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
October 30, 2025
Complaint health survey — 1 citation, worst grade G (actual harm)
September 12, 2025
Complaint health survey — 3 citations, worst grade G (actual harm)
July 24, 2025
Standard health survey — 14 citations, worst grade G (actual harm)
July 24, 2025
Fire-safety survey — 16 citations, worst grade F (potential for more than minimal harm)
June 5, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
February 12, 2025
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
January 30, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
August 15, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
August 7, 2024
Standard health survey — 13 citations, worst grade L (immediate jeopardy)
August 7, 2024
Fire-safety survey — 12 citations, worst grade F (potential for more than minimal harm)
May 15, 2024
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
May 6, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
March 1, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
December 29, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
November 13, 2023
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
August 30, 2019
Standard health survey — 10 citations, worst grade F (potential for more than minimal harm)
August 30, 2019
Fire-safety survey — 18 citations, worst grade F (potential for more than minimal harm)
Penalties imposed
July 24, 2025 — Fine of $160,666
July 24, 2025 — Payment denial · Medicare/Medicaid payments denied for 102 days from August 22, 2025
August 7, 2024 — Fine of $92,017
August 7, 2024 — Payment denial · Medicare/Medicaid payments denied for 38 days from September 6, 2024
Payment denials are the stronger federal sanction: CMS stops paying for new admissions until the home corrects the problems. Majestic Mountain Care Center has 2 denial periods on record totalling 140 days.
How Majestic Mountain Care Center compares with peer homes
Raw citation counts mean more in context. The table below compares Majestic Mountain Care Center with the median reviewed facility in Madera County (3 homes in this research set) and across California (350 homes), using the same CMS data. On health citations alone, Majestic Mountain Care Center sits above 50% of its reviewed county peers — in the worse half of the county.
Measure
This home
Madera Co. median
California median
Health citations on record
61
61
74
Citations from complaint investigations
24
24
27
Citations at actual-harm level or worse
6
6
2
Immediate-jeopardy citations
2
1
0
Total fines in CMS penalty records
$252,683
$252,683
$43,467
Penalty records (fines + payment denials)
4
5
2
What families should ask Majestic Mountain Care Center
- Ask why CMS flags Majestic Mountain Care Center with its abuse icon, which citations produced the flag, and what staffing or supervision changes followed.
- Ask for the plan of correction and follow-up monitoring for the infection prevention and control citations — most recently F-0880 on August 7, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the quality of life and daily care citations — most recently F-0686 on August 7, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the resident rights citations — most recently F-0577 on August 30, 2019 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the food, nutrition, and hydration citations — most recently F-0812 on August 30, 2019 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 2 totalling $252,683, the most recent dated July 24, 2025 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Majestic Mountain Care Center first document the change?
- Were recent complaint-related citations at Majestic Mountain Care Center connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
555115
Legal business name
OAKHURST SKILLED CARE LLC
Ownership type
For profit - Limited Liability company
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
August 6, 1979
Chain name
BAYSHIRE SENIOR COMMUNITIES
Certified beds
66
Average residents per day
61.1
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
2 star
Reported nurse staffing hours per resident day
3.76971
Total nursing staff turnover
66.7%
Public records are a starting point, not a conclusion
This profile of Majestic Mountain Care Center uses official CMS provider data as a research starting point. It does not state that Majestic Mountain Care Center abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Sources for Majestic Mountain Care Center
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.