Bayshore Nursing & Rehab: 39 Deficiencies Found - WI
One of those citations involved something foundational: whether residents were receiving accurate assessments.
Assessments are not paperwork. They are the mechanism by which a nursing home determines what a resident actually needs, what has changed, and what care plan should follow. When they are wrong, or incomplete, or conducted carelessly, the care that follows can be wrong too. Inspectors classified the assessment deficiency under tag F0641, which covers a facility's obligation to ensure each resident receives an accurate assessment, and they found it present as a pattern across the facility, not an isolated incident.
The scope and severity designation assigned was Level E: a pattern of deficient practice, with no actual harm documented but potential for more than minimal harm to residents. That language, "potential for more than minimal harm," is the threshold at which federal regulators consider a deficiency serious enough to require correction. The facility cleared that bar.
Thirty-nine times.
What the inspection report does not provide, and what the public record at this level of documentation rarely includes, is the specific detail behind each citation: which residents were affected, what was missed in their assessments, what care decisions followed from inaccurate information. The narrative released with this citation is brief. It confirms the deficiency, confirms the pattern, and confirms the correction date.
That correction date is November 12, 2025, roughly six weeks after inspectors walked through the door. The facility reported it had addressed the assessment deficiency by that date. Whether the fix extended to the other 38 citations, and what those citations covered, the public summary does not say.
The volume of deficiencies matters on its own terms. A single citation can reflect a documentation lapse, a staffing gap on a particular day, a policy that fell out of practice. Thirty-nine citations found during a single complaint inspection suggest something more systemic, a facility where multiple care and operational standards had slipped simultaneously. Inspectors do not generate 39 deficiencies by looking hard at one corner of a building.
This was a complaint inspection, meaning it was triggered by a concern reported to regulators, not a scheduled routine survey. Complaint inspections are targeted. They begin with a specific allegation and expand from there. When a complaint inspection produces 39 deficiencies, it means inspectors arrived with a reason and found considerably more than what brought them there.
Bayshore Nursing & Rehab is a nursing and rehabilitation facility serving residents who depend on the staff there for daily care, medication management, wound monitoring, therapy, and the basic documentation that keeps their care coordinated. Accurate assessment sits at the beginning of that chain. A resident whose cognitive status is underestimated may not receive the supervision they need. A resident whose pain is not properly captured in an assessment may not receive adequate treatment. A resident whose functional decline goes unrecorded may not be referred for the therapy that could slow it.
The assessment deficiency cited here was a pattern, not a single instance. That means inspectors found it repeated across more than one resident or more than one occasion, enough occurrences to constitute a systemic finding rather than an outlier.
The facility has since reported a correction. Regulators will determine, on a future visit, whether that correction holds.
What the record shows, as of the September 30 inspection, is a facility where the basic work of knowing who its residents are and what they need was not being done accurately, and where that failure was one of 39 things inspectors found worth citing before they left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayshore Nursing & Rehab from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
Bayshore Nursing & Rehab in GLENDALE, WI was cited for violations during a health inspection on September 30, 2025.
One of those citations involved something foundational: whether residents were receiving accurate assessments.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.