Majestic Mountain Care Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 62 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (22 vs median 13.0)
- High staff turnover (63%)
- High RN turnover (67%)
Bottom 25% in CA · Critically understaffed (RN) · Worst in BAYSHIRE SENIOR COMMUNITIES chain · $252,683 in fines · Special Focus Facility (CMS)
What this means for your family
This facility offers highly regarded rehabilitation services, particularly for stroke and physical therapy recovery. However, the recent influx of extremely serious allegations regarding patient safety and hygiene is a major red flag that requires direct investigation. If you choose this facility, you must verify staffing levels and safety protocols personally.
Google Reviews
Google Reviews
62 reviews analyzed“Families considering Majestic Mountain Care Center will find a polarizing landscape of experiences. While many recent reviews praise the exceptional physical therapy, rehabilitation for stroke recovery, and a kind, dedicated nursing staff, there are extremely serious allegations of physical abuse, neglect, and severe hygiene issues. Prospective families should weigh the high praise for rehab services against critical reports of staffing shortages and safety concerns.”
Quality Themes
Tap a score for detailsStrengths
- Outstanding rehabilitation and physical therapy
- Kind and attentive nursing staff
- Calm and relaxing atmosphere
- Welcoming and friendly environment
Concerns
- Allegations of severe physical abuse and injury
- Staffing shortages and understaffing (mentioned by 3 reviewers)
- Issues with hygiene and sanitation (mentioned by 2 reviewers)
- Communication and language barriers with staff (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution
How They Respond to Reviews
The owner uses personalized greetings and specific names in most responses. While positive reviews receive brief, friendly acknowledgments, negative reviews are met with a consistent, proactive attempt to move the conversation offline via a specific administrator's phone number.
Questions for Your Tour
- 1I noticed some families have shared how much they appreciate the physical therapy and rehab services here; could you tell me more about how the therapy team works with residents?
- 2With the recent inspections, what specific steps has the facility taken to address the recent state violations and improve the overall care environment?
- 3How does the nursing team ensure that communication remains clear and consistent with family members, especially if there are language differences?
- 4Could you describe the current staffing levels and how you ensure there is enough support for residents during busy shifts?
- 5What are the protocols in place for handling medical emergencies, and how is the clinical staff notified after hours?
- 6What does a typical day look like for residents in terms of daily activities and social engagement?
Personalized based on this facility's data
Key Review Excerpts
“Everyone was very nice, the nurses were exceptional! Always willing to talk and be there when you need it. Physical therapy was made for me personally, and I appreciate exceptional care.”
“New owners are changing the facility for the better. Very happy with all aspects of the care and attention provided my wife. In particular, the rehab is outstanding for stroke recovery.”
“My Mom spent 3yrs at the facility, before she past. I made friends with her two roommates and like to visit with them as well. Also, the staff has a place in my heart.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
10
measures
2
measures
5
measures
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Residents on antipsychotic medication
Residents whose walking got worse
Residents needing more daily help over time
Residents vaccinated for pneumonia
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed numerous complaints against this facility, with 23 complaint-triggered deficiencies across the records. The most recurring problems involve care planning and quality assessments, accident prevention and safety, and infection control. While most issues show correction dates, the facility has struggled with persistent safety hazards, medication management problems, and one recent quality care deficiency remains uncorrected as of January 2026, suggesting ongoing care quality concerns.
Mar 24, 2026Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Jan 28, 2026Complaint1
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Dec 2, 2025Complaint1
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Oct 30, 2025Complaint1
Quality of Life and Care Deficiencies
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.
Sep 12, 2025Complaint3
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Jul 24, 2025Routine30
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Environmental Deficiencies
Keep all essential equipment working safely.
Nutrition and Dietary Deficiencies
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.
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Resident Rights Deficiencies
Honor 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.
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.
Nutrition and Dietary Deficiencies
Ensure 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.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Provide properly protected cooking facilities.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Emergency Preparedness Deficiencies
Develop a communication plan.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Federal Penalties
Fine
Jul 24, 2025
$160,666
Payment Denial
Jul 24, 2025
102-day denial
Fine
Aug 7, 2024
$92,017
Payment Denial
Aug 7, 2024
38-day denial
Ownership & Operations
Who Operates This Facility
Majestic Mountain Care Center
for profit
Chain Affiliation
Bayshire Senior Communities
12 facilities nationwide
Chain avg rating: 3.1/5 · Rank 10 of 11 (Worst)
Ownership & Management
Owners
Bayshire Central Valley LLC
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
62 reviews from families & visitors
Official Website
Visit majesticmtn.com
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.