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Nursing HomeMedicaid Investigative

Majestic Care of South Bend

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

52654 N Ironwood Rd, South Bend, IN 46635103 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 50 Google reviews

5
4
3
2
1
Majestic Care of South Bend Nursing Home in South Bend, IN — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (8 vs median 6)
  • High staff turnover (75%)
  • High RN turnover (80%)

Below average in IN · Below recommended RN staffing · Very high staff turnover · Below chain average · $116,322 in fines

Source: Medicare data

What this means for your family

While some families report positive experiences with the therapy team and recent facility updates, the recurring reports of neglect and poor communication are significant red flags. We strongly advise visiting during off-hours or weekends to verify staffing levels and responsiveness before making a decision.

Google Reviews

Google Reviews

50 reviews on Google
Majestic Care of South Bend receives highly polarized feedback, with some residents and families praising the staff's kindness and recent facility improvements, while others report severe neglect, poor hygiene, and management failures. Critical concerns include inconsistent communication, poor food quality, and significant staffing shortages, particularly on weekends. Families should exercise caution and conduct thorough, in-person visits to assess current conditions.

Quality Themes

Tap a score for details
Food2.0Staff5.0Clean3.0Activities8.0MedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Kind and compassionate nursing staff
  • Helpful physical therapy team
  • Recent facility aesthetic improvements
  • Responsive maintenance staff

Concerns

  • Neglect and poor patient care (unanswered call lights, hygiene issues) (mentioned by 5 reviewers)
  • Poor communication and difficulty reaching staff by phone (mentioned by 4 reviewers)
  • Inadequate staffing and management presence on weekends (mentioned by 3 reviewers)
  • Poor food quality and dining experience (mentioned by 4 reviewers)
  • Facility cleanliness and hygiene standards (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'18(3)'20(6)'22(3)'24(7)'26(8)

Distribution · 51 analyzed

5
32
4
5
3
2
2
0
1
12

How They Respond to Reviews

33%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1I noticed the facility has undergone some recent aesthetic improvements; how are you planning to build on those updates to further enhance the living environment for residents?
  • 2With the current staffing levels, what specific protocols do you have in place to ensure that call lights are answered promptly and that residents receive timely assistance with hygiene needs?
  • 3We understand that communication is vital for families; what is the best way for us to reach the nursing team directly if we have questions about our loved one’s care, especially during the weekend?
  • 4I see that you actively engage with online feedback; how does the management team use that input to make tangible improvements to the dining experience and food quality?
  • 5Could you walk us through your process for monitoring resident health and how you handle medical emergencies or urgent changes in condition during evening and weekend hours?
  • 6What does a typical day look like for a resident here, and how do you ensure there are consistent, engaging activities for those who might need extra encouragement to participate?

Personalized based on this facility's data


Key Review Excerpts

The food is not that good.the most staff is very kind and caring. physical therapist is very knowledgeable and helpful towards me..

Rehab patient · 2024★★★★

I stopped in during the 4th of July holiday just to make sure my dad was well, because I know that they have had some staffing issues. I was pleasantly surprised. There seemed to be plenty of staff on the shift moving about seeing after residents and helping assist one another.

Long-term resident's family · 2024★★★★

The place is so dirty and nasty. I wouldn't let my dog stay there. They didn't take care of my mother and she fell and it took two days to get her to the hospital and her knee was shattered.

Long-term resident's family · 2025☆☆☆☆
Source: 50 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.62hrs
83%
Registered nurses for medical care
Total Nursing
3.43hrs
84%
All nurses + aides combined
Staff Turnover
72%
Lower is better (< 30% = good)
RN Turnover
75%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

8

measures

Worse Than Avg

5

measures

Mixed Results

4

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
15.3%
IN
13.0%
St. joseph
17.7%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility81.9%
Worse than Avg
Here
81.9%
US
95.5%
IN
95.4%
St. joseph
97.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility2.7%
Better than Avg
Here
2.7%
US
14.4%
IN
11.4%
St. joseph
15.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility15.8%
Mixed vs Avgs
Here
15.8%
US
12.1%
IN
24.8%
St. joseph
10.6%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
IN
93.6%
St. joseph
96.3%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility9.9%
Worse than Avg
Here
9.9%
US
5.3%
IN
5.6%
St. joseph
6.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility12.5%
Worse than Avg
Here
12.5%
US
79.7%
IN
79.0%
St. joseph
89.8%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
IN
81.5%
St. joseph
87.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility13.2%
Worse than Avg
Here
13.2%
US
1.6%
IN
1.3%
St. joseph
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

8deficiencies
4penalties
Above state avg (7.6)
15 complaint-triggered
$116,322 in fines

Majestic Care has recurring problems with nursing staffing, medication management, and fire safety violations across multiple surveys, with 16 complaint-triggered deficiencies indicating families have filed reports about care concerns. Issues persist across years despite corrections, including repeated failures with emergency response, dietary safety, staff competency, and building safety systems. While all deficiencies show correction dates, the pattern of ongoing problems suggests systemic challenges in maintaining consistent care standards.

Jan 16, 2026Complaint
2
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Aug 19, 2025Routine
30
0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0927Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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.

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0211Potential for harm · PatternCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0281Potential for harm · PatternCorrected

Egress Deficiencies

Install proper backup exit lighting.

0293Potential for harm · PatternCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0511Potential for harm · PatternCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0812Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0223Potential for harm · IsolatedCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0025Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

0039Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Oct 4, 2024Routine
22
0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0032Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide primary/alternate means for communication.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0657Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0511Potential for harm · PatternCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0582Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0693Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0921Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Aug 23, 2024Complaint
3
0698Immediate jeopardy · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Jul 15, 2024Complaint
4
0678Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0921Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Feb 20, 2024Complaint
2
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Federal Penalties

Fine

Jul 15, 2024

$16,801

Fine

Jul 15, 2024

$84,256

Payment Denial

Jul 15, 2024

34-day denial

Fine

Aug 28, 2023

$15,265

Ownership & Operations

Who Operates This Facility

Owner / Operator

Majestic Care of South Bend

Organization Type

for profit

Chain Affiliation

Chain Name

Majestic Care

Chain Size

35 facilities nationwide

Chain avg rating: 2.6/5 · Rank 22 of 34

Ownership & Management

Owners

Jackson County Schneck Memorial Hospital

Owner · Organization

100%

Jackson County Schneck Memorial Hospital

Owner (parent company) · Organization

100%

Key personnel

Bevers, SusanManaging Control - Governing BodyFish, EricManaging Control - Governing BodyGilliland, TerrenceManaging Control - Governing BodyHarpe, BrandonManaging Control - Governing BodyKleber, CourtneyManaging Control - Governing Body
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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