Bayshore Nursing & Rehab: Smoking Safety Failures - WI
The inspection, completed September 30, 2025, stemmed from a complaint. What surveyors found was not a paperwork problem. It was a cognitively impaired resident, alone, dropping lit cigarettes on the ground and walking away from them.
When the surveyor asked the resident, identified in inspection records as R40, what happened to a finished cigarette, the resident said they just toss it on the ground. The surveyor asked whether anyone steps on it to put it out. R40 said no. The surveyor watched long enough to confirm it: R40 dropped a lit cigarette onto the ground and no staff member was anywhere nearby.
The burn hole in the sweatpants was already there.
Bayshore's Director of Nursing, identified in the report as DON-B, told the surveyor that the facility does not determine smoking supervision based on a resident's cognitive status. Instead, she said, supervision decisions come from smoking safety assessments completed at admission and every three months after that.
The surveyor then walked DON-B through R40's actual record.
R40 was admitted to the facility, and the first smoking safety assessment did not happen until November 11, 2024, four and a half months after admission. The next one was not completed until June 24, 2025, seven months after that. A third assessment was dated August 28, 2025. Three assessments total, none completed on the schedule the DON described, and all three flagged by the surveyor as containing incomplete documentation.
There was no assessment done at admission. There was no assessment for the first four and a half months R40 lived at the facility and smoked there.
DON-B told the surveyor the facility is now completing the assessments on time.
The surveyor pressed further. R40 had a care plan that included specific interventions for smoking. The surveyor told DON-B that the care plan was not being followed. DON-B said she understood. She said she was aware the care plan was not being followed.
That was the answer. Not a dispute, not a correction. Awareness.
Federal inspectors classified the violation as causing actual harm, not the potential for it. The harm level distinction matters in CMS enforcement. Surveyors do not check that box for paperwork gaps. They check it when something has already gone wrong for the resident.
The burn hole in the sweatpants was the evidence sitting in plain view.
Smoking in nursing homes occupies a narrow and genuinely difficult space. Residents retain the right to smoke. Facilities cannot simply prohibit it for cognitively impaired residents without individual assessment and justification. The obligation runs in both directions: protect the resident from harm, and do not strip the resident of autonomy without cause. Bayshore's own system, the smoking safety assessment completed at admission and quarterly, was designed to navigate exactly that tension. The system existed. It just was not used.
For four and a half months after R40 moved in, nobody completed the assessment that was supposed to determine how much supervision R40 needed while smoking. For seven months after that first assessment, nobody completed the next one. And on the afternoon a surveyor happened to be watching, R40 dropped a lit cigarette on the ground and walked away from it, alone.
DON-B did not tell the surveyor the care plan was being followed and the surveyor had it wrong. She said she knew it wasn't.
R40's sweatpants already had the burn hole to prove it.
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 16, 2026 · Our methodology
Bayshore Nursing & Rehab in GLENDALE, WI was cited for violations during a health inspection on September 30, 2025.
The inspection, completed September 30, 2025, stemmed from a complaint.
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.