Home / California / Oakhurst
40131 Highway 49, Oakhurst, CA 93644 · Madera County · (559) 683-2244
66 certified beds, about 60 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1979
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555115 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 24, 2025, inspectors cited 14 health deficiencies (the California average is 15.6, the national average 9.2).
Of 61 health citations since August 2019, 6 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 2 fines totaling $252,683 in the last three years; the largest was $160,666, and the latest is dated July 24, 2025.
Nurses and nurse aides worked 3.48 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.33 of those hours.
69.0% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Jericho Care Group, an affiliated group of 7 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 61 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when facility staff did not provide supervision for Resident 1 when Resident 1 exited the facility through the back patio door, wandered off the facility perimeter that did not have a fence or barrier dividing the front and back of the facility and was located in a rough terrain area with tall grass, tall bushes, long tree branches, mud and a water hole. This failure had the potential to cause falls and injuries to Resident 1 and other Residents in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for one of three sampled residents (Resident 1) when Resident 1, was left unattended in bed lying on his right side by Licensed Vocational Nurse (LVN) during wound-care treatment (specialized medical management of skin injuries to promote healing and prevent infection) on [DATE], while the right side of his bed had no bedrail in place. This failure resulted in Resident 1 falling from his bed onto the floor causing an avoidable left hip fracture (broken bone) and mild pain. During a concurrent observation and interview on [DATE] at 9:17 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1 was covered with a blanket that notably outlined his bilateral (left and right) above the knee amputations (removal of limbs). [...]
Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedure (P&P) titled Abuse Prevention and Response Policy to ensure residents were free from abuse and neglect for two of six sampled residents (Resident 1 and Resident 3) when:1. Social services was made aware of Resident 1's allegation of sexual abuse and did not investigate or document the incident. This failure placed Resident 1 at risk for further abuse, neglect and emotional harm.2. Licensed Vocational Nurse (LVN) 3 left Resident 3 unsupervised outside the facility front door for 15-20 minutes and Resident 3 left the facility. This failure placed Resident 3 at risk for harm due to the facility being located on a busy highway, at risk for falls and injury.
Inspectors wroteBased on interview and record review, the facility failed to ensure violations involving abuse were reported for one of three sampled residents (Resident 1) when facility staff did not report an allegation of abuse for Resident 1's report of sexual abuse involving Resident 2 touching her breast without consent. This failure placed Resident 1 safety at risk and there was potential for further abuse.
Inspectors wroteBased on interview and record review the facility failed to meet professional standards of practice and follow the policy and procedure titled, Nursing Assessment and Management of Residents Following a Fall, for one of three sampled residents (Resident 1), when LVN 1, CNA 1 and CNA 2 observed Resident 1 on 1/16/26 exhibit restless and anxious behavior, exit seeking behavior and wheeling herself into other resident rooms trying to get into their beds. LVN 1 did not assess the situation, did not assess Resident 1 at the time of the behaviors and did not notify the physician to provide instructions on how to address Resident 1. Instead, LVN 1 instructed CNA 1 and CNA 2 to put Resident 1 to bed and Resident 1 was found on the hallway floor outside her room [ROOM NUMBER] minutes later. [...]
Inspectors wroteBased on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to notify the Resident 1 of the transfer or discharge, the reasons for the move in writing and in a language and manner they understand, develop and implement an effective discharge planning process that focuses on the resident's discharge goals and after the hospitalization, the facility refused to re-admit Resident 1 in accordance with court order. This failure placed Resident 1 at risk for loss of safety, homelessness, and delay in care.
Inspectors wroteBased 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]. [...]
Inspectors wroteBased 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. Nursing staff did not consider a physical therapy evaluation for a new wheelchair with anti-tilt bars. [...]
Inspectors wroteBased 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. Afterwards, Resident 1 complained of head and neck pain that radiated to the right side and nurses did not effectively treat the pain. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of five sampled residents (Resident 1), when the facility staff did not complete documentation of Resident 1's fall or possible injuries and did not follow up with cervical (neck) x-ray results for three weeks following Resident 1's fall on 7/25/25. This failure resulted in delay in assessment and treatment for Resident 1 due to a potential injury following the fall on 7/25/25. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 19 sampled residents (Resident 41), when Resident 41 experienced an unplanned weight loss of six pounds (3.4%) in one month (2/1/25-3/1/25), nine pounds (5.3%) in one month (5/1/25-6/1/25), and 23 pounds (13.7%) in five months (2/1/25 - 7/7/25), and interventions to prevent weight loss were not recommended and implemented in a timely manner. [...]
Inspectors wroteBased on interview and document review, the facility failed to have qualified, full-time oversite of Food and Nutrition Services. This deficient practice could result in compromising the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 55 residents who received food from the kitchen out of a census of 56.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff had the appropriate competencies to carry out the functions of the food and nutrition service when: 1. [NAME] 2 was not competent in the use of the dish machine and testing the dish machine sanitizer strength. 2. [NAME] 1 was not competent preparing pureed food. 3. [NAME] 1 and the Dietary Supervisor (DS) were not competent in the use of the three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing). These failures had the potential to result in contamination of resident food and utensils used by residents leading to illness for 55 who received food from the kitchen; [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were prepared by methods that conserve flavor, appearance, and at an appetizing temperature when: 1. The temperature of the ham, cauliflower, and sweet potato wedges served for the lunch meal was below 120 degrees Fahrenheit (F-unit of measurement) and barely felt warm in the mouth when sampled. 2. The pureed ham, cauliflower, and sweet potato wedges served for the lunch meal were a thin, runny consistency. 3. The pureed sweet potato wedges were bland. These failures had the potential to result in weight loss and/or further complicate medical status of residents for 55 residents who received food from the kitchen out of a census of 56.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The dish machine was used without reaching 120 Fahrenheit (F-Unit of measurement) and without sanitizer. 2. The ice machine was not clean and was not cleaned according to the manufacturer's instructions. 3. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation and was not clean. 4. Kitchen floors, ceiling panels, walls, doors, and screens were not maintained in good condition. 5. The area underneath the three-compartment sink was not clean. 6. A can-opener and serving trays were not clean. 7. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure arbitration agreements were explained to residents in a manner they could understand for 57 of 57 residents when the Admissions Coordinator (AC) did not explain arbitration to newly admitted residents. This failure violated the rights of 57 of 57 residents residing in the facility to be properly informed of the arbitration process and agreement. During an interview on 7/23/25 at 10:54 a.m., with the AC, The AC stated she gave residents the arbitration agreement upon their admission to the facility. The AC stated she did not explain what arbitration was to any resident who were newly admitted . The AC stated she had residents review the agreement with the rest of the admission packet on their own time. The AC stated she did not know what arbitration was and therefore had never explained it to any resident. [...]
Inspectors wroteBased on interviews and record reviews, the facility failed to implement adequate measures and a comprehensive water management plan to minimize the risk of Legionella (a harmful bacterium that lives in water systems and areas that are continuously wet) and other pathogens in the building's water system. This failure had the potential to expose 57 of 57 residents to Legionnaires' disease (a disease caused by legionella which affects the lungs) or other opportunistic infections.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when: 1. The three-compartment sink (piece of equipment used in professional kitchens for manual dishwashing and consists of three compartments: the first for washing, the second for rinsing, the third for sanitizing) was used for food preparation, did not drain, causing water and debris to back up into the sink. 2. The three-compartment sink was used as a food preparation sink and did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 3. The facility did not have drain plugs in order to plug the sinks of the three-compartment sink, so the sink could be used in the way it was intended for ware washing. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, comfortable, homelike environment for four of 19 sampled residents (Resident 12 , 16. 31 and 38) when:1. Resident 12 was not provided with a mattress that was comfortable for him. This failure caused Resident 12 to be uncomfortable and not receive restful sleep.2. Resident 31 and Resident 38's room had two white painted patches approximately the size of 3.5 x 1.5 and 9 x 3 feet on the wall next to the door leading to the corridor. This failure had the potential for Resident 31 and Resident 38 to feel depressed and was not homelike environment.3. Resident 31 and Resident 38 shared restroom that had brown like substance on the seat of the toilet, personal items on the floor and top of the toilet. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sample staff Licensed Vocational Nurse (LVN 2), when LVN 2 did not had the annual nursing skills training competency completed according to facility's policy and procedure (P&P) Nursing Skills Training and Competency Policy. This failure had the potential for areas of improvement to be identified for LVN 2 which placed all residents at risk for their health and safety.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fortified (foods that have essential nutrients added to them, typically to improve their nutritional value or address nutrient deficiencies) diets were prepared according to facility fortified menu for 6 of 6 residents (Resident 2, 3, 18, 24, 26, and 56). This failure had the potential to result in weight loss and/or further complicate medical status for Resident 2, 3, 18, 24, 26, and 56 who received a prescribed fortified diet out of a of 56 residents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure, the rights of residents' individual needs and preferences were provided for one of 19 sampled residents (Resident 22), when the call light in Resident 22's room was not fixed and she was not able to return to her room since 6/6/25. This failure resulted in Resident 22 feeling nervous and had the potential for her to be depressed.
Inspectors wroteBased on observation, interview and record review the facility failed to complete a performance review (a formal assessment of a nurse aide's job performance, covering areas like clinical competence, communication, teamwork, and professionalism, to identify strengths and areas for improvement) of every nurse aide at least once every 12 months for one of two sampled Certified Nursing Assistant (CNA 2) when CNA 2 did not receive nurse aide performance review every 12 months. This failure resulted in CNA 1 not getting their performance evaluated and had the potential for weak areas not to be identified and improved which could affect resident care.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' preferences were honored for one of 19 sampled residents (Resident 20) when, Resident 20's meal card (printed ticket or document associated with each resident that details their specific dietary needs, preferences, allergies, adaptive equipment requirements, and even dislikes, ensuring personalized meal delivery and safety) did not have anything listed on his dislikes and the meal card was not updated to include his dislikes for fishes. This failure resulted in Resident 20 feeling unheard when served disliked food and had the potential for weight loss from not eating.
Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered according to professional standards of practice for one of six sampled residents (Resident 1), when Resident 1 was not administered medication metformin (medication used for the treatment of diabetes a condition in which there is too much sugar in the blood), enoxaparin (medication used as a blood thinner to prevent blood clots), and nystatin powder (medication used to treat a fungal infection) according to physician orders due to medication unavailability in the facility. This failure had the potential to result in medication ineffectiveness resulting in blood clots that could have led to stroke (interruption in blood supply to the brain) or death, high blood sugar or uncontrolled blood sugar, and worsening of active fungal infection for Resident 1.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents at risk for elopement received adequate supervision and monitoring to prevent accidents for one of six sampled residents (Resident 2), when on 6/1/25 Resident 2 left the facility through the front door and walked half a mile to a grocery store. This failure had the potential for Resident 2 to result in injury caused by falls due to areas of uneven terrain (land that is not flat, varies in height, may have bumps or holes making it difficult to walk)), motor vehicle accident due to a busy highway located next to the facility, and heat exhaustion due to rise in temperature of over 90 degrees Fahrenheit (unit of measurment) for Resident 2.
Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse according to the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, for one of three sampled Residents (Resident 1), when Resident 1 reported a resident-to-resident verbal altercation to licensed vocational nurse (LVN) 1 on 2/9/25 and LVN 1 failed to report the incident . This failure resulted in the incident of abuse being reported three days later causing Resident 1 distress when Resident 1 continued to encounter Resident 2 during smoking breaks and was not monitored or separated by the facility staff. This failure exposed Resident 1 to further verbal altercations and emotional distress.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow the policy and procedure, titled Abuse, Neglect and Exploitation to ensure residents were free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA) 1 deliberately cut Resident 1's hair without permission and disregarding Resident 1's personal preference to grow and donate her hair to charity. This failure resulted in emotional distress causing unnecessary mental trauma evidence by Resident 1 feeling angry, sad, betrayed and expressing feelings of being cautious, scared and vigilant in the facility following the incident.
Inspectors wroteBased on observation interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet psychosocial needs according to the policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of four sampled Residents (Resident 1), when Resident 1 ' s preference to grow her hair to donate to charity was not documented as part of the plan of care in the care plan. This failure resulted in psychosocial and emotional harm for Resident 1, when her hair was deliberately cut by certified nursing assistant (CNA) 1 and stated she was feeling betrayed, angry and sad.
Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of quality for one of five sampled residents (Resident 1), when Resident 1 had an unwitnessed fall on 8/6/24 and the facility staff did not complete a change of condition assessment, skin assessment and post fall assessment. This failure resulted in incomplete documentation for Resident 1 and put Resident 1 at risk for falls and potential delay in care.
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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. [...]
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide a response and resolution for resident grievances in a timely manner. This deficiency had the potential to affect all residents that resided in the facility.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide a means for residents to file an anonymous grievance. This deficiency had the potential to affect all residents that resided in the facility.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented for 3 (Residents #29, #42, and #50) of 5 sampled residents reviewed for unnecessary medications.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate less than 5 percent (%). The facility had 4 errors out of 28 total opportunities, resulting in a medication error rate of 14.28%, affecting 2 (Resident #61 and Resident #43) of 5 residents observed during medication administration.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician when new pressure ulcers were identified and when nursing staff noted increased wound measurements or a decline in the condition of pressure ulcers for 2 (Resident #15 and Resident #46) of 4 sampled residents reviewed for pressure ulcers.
Inspectors wroteBased on interview, record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete Minimum Data Set (MDS) assessments timely for 1 (Resident #21) of 20 sampled residents' whose electronic medical records were reviewed.
Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the presence of a serious mental illness per the state Level II Preadmission Screening and Resident Review (PASRR) process for 1 (Resident #15) of 4 residents reviewed for PASRR requirements.
Inspectors wroteBased on interview, record review, and facility document review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) assessment for 1 (Resident #40) of 2 residents reviewed for PASRR.
Inspectors wroteBased on interview, record review, facility document review, and review of a memorandum from the California Department of Health Care Services, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I screening was resubmitted for 1 (Resident #39) of 4 residents reviewed for PASRR. Specifically, the facility failed to resubmit a Level I screening to re-open their case when a Level II evaluation could not be completed due to the resident being hospitalized .
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the care plan was updated with fall interventions for 1 (Resident #39) of 4 residents reviewed for accidents.
Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure an environment free of accidents and hazards for 1 (Resident #39) of 4 residents reviewed for accidents. Specifically, the facility failed to prevent repeat falls for Resident #39.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident rights were implemented according to the facility's policy and procedure (P&P) for call lights and Resident rights for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when Resident 1, Resident 2, and Resident 3's call lights were ignored while CNAs were observed by staff and residents to be using personal cellphones and not providing requested assistance. This failure resulted in Resident 1, Resident 2 and Resident 3 to have feelings of being ignored, loss of dignity and respect from the facility staff and had the potential to cause skin breakdown and falls when requested assistance to use the restroom or changing of soiled briefs was not honored.
Inspectors wroteBased on interview and record review, the facility failed to report a sexual abuse allegation in accordance with the facility's policy and procedure and state regulations, for one of three sampled residents (Resident 1), when Resident 1 reported alleged sexual abuse to Licensed Vocational Nurse (LVN) 1 and the allegation was not reported immediately to the State Licensing Agency and Adult Protective Services as required by law. This failure resulted in a delayed investigation of the alleged sexual abuse and placed Resident 1 at risk for physical, emotional, and psychological harm.
Inspectors wroteBased on interview, and record review the facility failed to provide necessary care and services to ensure that residents ' abilities in activities of daily living did not diminish for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 did not receive showers as scheduled. These failures resulted in Resident 1 and Resident 2 not having their needs met and feeling like staff did not care.
Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for one of four sampled staff members (Licensed Vocational Nurse (LVN) 1) when the facility did not follow its policy and procedure (P&P) UNIFORM AND DRESS CODE ACKNOWLEDGEMENT and LVN 1 was observed to have long black acrylic (fake) nails on. This failure had the potential to spread germs/infection between residents/staff and placed residents at risk of injury from the nails.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of six sampled residents (Resident 4) when Resident 4 was assessed with a pressure injury (PI -localized damage to the skin as well as underlying soft tissue) on 11/14/22 and a care plan was not developed and implemented to address the PI. Resident 4 was admitted to the Acute Care Hospital (ACH) on 11/24/23 and returned to the facility on [DATE] with an unstageable PI (when the PI depth cannot be determine because the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) and a care plan identifying effective interventions was not developed and implemented. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect in an environment that promoted and enhanced their self-esteem for one of three sampled residents (Residents 1) when the urinary catheter (a flexible tube inserted into the bladder to drain urine) bag for Resident 1 was uncovered. This failure resulted in Resident 1 feeling embarrassed.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Residents 1 did not have a care plan for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). This failure placed resident 1 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. One of three sampled residents restrooms (Resident 1's) portable raised toilet seat (equipment goes on top of a toilet bowl to increase its height) had a brown colored smear. 2. One of three sampled residents (Resident 1's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. This failure had the potential for cross contamination.
Inspectors wroteBased on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure resulted in depriving residents and visitors the opportunity and of their right to view abbreviated survey findings and plans of correction (POC) for the facility.
Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and sanitary environment in the kitchen for 62 of 64 sampled residents' when: 1. Brownish liquid was observed leaking from a garbage disposal. 2. Two broken dusty meal carts were stored in the kitchen. 3. Vent screen on the ice machine was covered with dust. 4. Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals from the kitchen.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Six of eight sampled residents (Resident's 415, 48, 16, 414, 42, and 3's) oxygen tubing were not dated and appropriately stored to prevent cross contamination. 2. Spoiled tomatoes were stored in the refrigerator, a tub of ice cream was dripping in the freezer, one bag of noodles in the pantry were expired. 3. One of three sampled residents (Resident 49's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. These failures had the potential for cross contamination (transfer of germs) and spread of infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy and confidentiality of residents personal and medical information for two of seven sampled residents (Resident 51 and Resident 28), when Registered Nurse (RN) 1 left the Medication Administration Record (MAR) open and easily visible in the hallway with Resident 51 and Resident 28's personal and medical information exposed and visible to other residents, staff and visitors passing by. This failure had the potential to result in the unauthorized access to Resident 51 and Resident 28's personal and medical information and violated Resident 51 and Resident 28's rights to confidentiality.
Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable homelike environment for one of 31 sampled residents (Resident 27) when Resident 27's dresser had visible dust. This failure resulted in an unclean and uncomfortable environment for Resident 27.
Inspectors wroteBased an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 47) when a care plan for Resident 47's anti-coagulant (blood thinner) medication was not developed. This failure placed Resident 47 at risk of not receiving appropriate, consistent, and individualized care and monitoring interventions to ensure adverse affects of the blood thinner such as excessive bleeding were identified.
Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for two of five sampled residents (Resident 33 and Resident 3) when: 1. Registered Nurse (RN 1) used an inappropriate medication administration technique while using an insulin pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation for Resident 33. This failure placed resident 33 at risk for dosing errors and had the potential for adverse effects such as hyperglycemia (high blood sugar). 2. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a performance review of every nurse aide at least once every 12 months was completed for two of 15 Certified Nursing Assistants (CNAs) CNA 2 and CNA 3. These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews.
Inspectors wroteBased on interview, and record review the facility failed to ensure as needed (PRN) Psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) were time limited to 14 days for two of four sampled residents (Resident 14 and Resident 15) when: 1. PRN Lorazepam (medication to treat anxiety) was prescribed Resident 14 since 3/19/19 without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. 2. PRN Lorazepam was prescribed for Resident 15 since 5/3/19, without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to the maintain garbage disposal and ice machine equipment in safe operating condition when: 1. Brownish liquid was observed leaking from a garbage disposal onto a pan on the kitchen floor. 2. The Vent screen on the ice machine was covered with dust. 3. The Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals and ice from the kitchen.
46 fire safety citations on file: 16 on July 24, 2025, 12 on August 7, 2024, 18 on August 30, 2019.
| Date | Penalty | Amount or length |
|---|---|---|
| July 24, 2025 | Fine | $160,666 |
| July 24, 2025 | Payment Denial | 102 days from August 22, 2025 |
| August 7, 2024 | Fine | $92,017 |
| August 7, 2024 | Payment Denial | 38 days from September 6, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.48 | 4.52 | 3.86 |
| Registered nurses | 0.33 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.44 | 4.09 | 3.42 |
| Nurse aides | 2.23 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | 69.0% | 36.7% | 45.8% |
| Registered nurse turnover | not reported | 38.1% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.50 on weekdays and 3.44 on weekends, 2% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 25.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.62 in April to June 2025 to 3.48 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.48 | 0.33 | 3.50 | 3.44 | 25.0% | 0 of 90 | 60 |
| Oct to Dec 2025 | 3.77 | 0.29 | 3.88 | 3.50 | 36.3% | 0 of 92 | 61 |
| Jul to Sep 2025 | 3.42 | 0.33 | 3.53 | 3.13 | 31.4% | 0 of 92 | 60 |
| Apr to Jun 2025 | 3.62 | 0.30 | 3.71 | 3.42 | 27.4% | 0 of 91 | 63 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.5 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.9 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.5 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.5 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 6.1 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.8 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 20.7 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Majestic Mountain Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (43.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
43.5% this home
No different from the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 65 eligible stays.
9.7% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 71 eligible stays.
9.0% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 54 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 16 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 33 residents counted.
3.0% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 33 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 7 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: OAKHURST SKILLED CARE LLC. CMS links this home to Jericho Care Group, a group of 7 nursing homes averaging 2.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bayshire Central Valley LLC | 5% or greater direct ownership interest | Organization | 100% | 05/01/2024 |
| Parrott, Jason | Corporate director | Individual | 01/30/2023 | |
| Carter, Benjamin | Operational/managerial control | Individual | 05/01/2024 | |
| Coleman, Chad | Operational/managerial control | Individual | 06/01/2023 | |
| Grossman, Stephen | Operational/managerial control | Individual | 01/30/2023 | |
| Kirby, Scott | Operational/managerial control | Individual | 05/01/2024 | |
| Parrott, Jason | Operational/managerial control | Individual | 01/30/2023 | |
| Salow, Donald | Operational/managerial control | Individual | 05/01/2024 | |
| Carter, Benjamin | Adp of the SNF | Individual | 05/01/2024 | |
| Coleman, Chad | Adp of the SNF | Individual | 06/01/2023 | |
| Grossman, Stephen | Adp of the SNF | Individual | 01/30/2023 | |
| Kirby, Scott | Adp of the SNF | Individual | 05/01/2024 | |
| Parrott, Jason | Adp of the SNF | Individual | 01/30/2023 | |
| Salow, Donald | Adp of the SNF | Individual | 05/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.