Majestic Care of South Bend
52654 N Ironwood Rd · South Bend, IN · 46635 · 5742778710
103 certified beds For profit - Individual Chain: Majestic Care
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $101,057 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$101,057 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
72% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.43 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.62 | 0.55–0.75 |
| Weekend hours / resident-day | 2.97 | ≈ weekday level |
| Nursing turnover / year | 72% | median 45% |
| Fines (3-yr window) | 3 · $116,322 |
Inspection citations (52 in the current record)
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Potential for harm · D January 16, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 30, 2026 · Resident Rights
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Potential for harm · F January 16, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 30, 2026 · Nutrition and Dietary
-
Potential for harm · D August 19, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected September 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 19, 2025
Provide activities to meet all resident's needs.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · E August 19, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · E August 19, 2025
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.
Corrected September 29, 2025 · Nursing and Physician Services
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Potential for harm · D August 19, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 29, 2025 · Nutrition and Dietary
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Potential for harm · D August 19, 2025
Provide and implement an infection prevention and control program.
Corrected September 29, 2025 · Infection Control
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Potential for harm · D October 4, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected November 7, 2024 · Resident Rights
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Potential for harm · D October 4, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected November 7, 2024 · Resident Rights
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Potential for harm · D October 4, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 7, 2024 · Resident Rights
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Potential for harm · D October 4, 2024
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.
Corrected November 7, 2024 · Resident Rights
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Potential for harm · D October 4, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 7, 2024 · Resident Assessment and Care Planning
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Potential for harm · E October 4, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected November 7, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 4, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 7, 2024 · Quality of Life and Care
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Potential for harm · D October 4, 2024
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.
Corrected November 7, 2024 · Quality of Life and Care
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Potential for harm · D October 4, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected November 7, 2024 · Pharmacy Service
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Potential for harm · E October 4, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 7, 2024 · Nutrition and Dietary
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Potential for harm · D October 4, 2024
Provide and implement an infection prevention and control program.
Corrected November 7, 2024 · Infection Control
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Potential for harm · D October 4, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected November 7, 2024 · Environmental
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Immediate jeopardy · K August 23, 2024 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected September 12, 2024 · Quality of Life and Care
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Potential for harm · D August 23, 2024 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected September 12, 2024 · Resident Rights
-
Potential for harm · E August 23, 2024 · found via complaint
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.
Corrected September 12, 2024 · Nursing and Physician Services
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Immediate jeopardy · J July 15, 2024 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected August 8, 2024 · Quality of Life and Care
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Potential for harm · F July 15, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 12, 2024 · Nursing and Physician Services
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 15, 2024 | Fine | $16,801 |
| July 15, 2024 | Fine | $84,256 |
| July 15, 2024 | Payment Denial | 34 days |
| August 28, 2023 | Fine | $15,265 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 155219 · certified since August 4, 1983. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.