Bayshore Nursing & Rehab: Abuse Reporting Failures - WI
That was August 5, 2025. Police were not called until September 16, 2025, and only after the inspector, already on-site for a complaint investigation, told facility leadership the allegations still hadn't been reported.
By then, the resident wasn't even in the building.
The inspection report filed against Bayshore Nursing & Rehab, located at 1300 West Silver Spring Drive in Glendale, describes a failure that compounded over six weeks and across multiple levels of management, each person assuming someone else had made the call. Nobody had.
The resident, identified in inspection records as R66, first reported the incident through a grievance filed on August 5. The documented grievance, reviewed by the inspector, recorded two separate complaints: the nursing assistant, referred to as CNA-X, had entered R66's room without knocking while R66 was naked, and R66 felt disrespected. The same grievance form documented a second allegation, that CNA-X told R66 directly that CNA-X "will not be doing shit" for her.
The administrative director who wrote up that grievance form told the inspector she considered it abuse and sent it to the Director of Social Services the same day.
The Director of Social Services, identified as DSS-F, told the inspector on September 11 that after interviewing R66, there were no statements from R66 about physical or verbal abuse. DSS-F also said, that same afternoon, that she didn't know the full scope of what had been alleged on August 5. When the inspector sat down with DSS-F and reviewed the grievance form together, DSS-F acknowledged what was written on it. "What was documented on this grievance would need to be reported," DSS-F said.
That conversation happened on September 11. The report still wasn't filed.
On September 9, four days before that exchange, the inspector had already surfaced a second set of allegations. R66 had made additional statements, and the inspector reported those directly to the nursing home administrator, identified as NHA-A, at 2:29 PM. The next day, NHA-A told the inspector the facility had reported the September 9 allegations to the state. That turned out to be wrong. NHA-A later acknowledged the report had been made in error.
By September 16, the inspector had been on-site for days and still could not locate documentation that either the August 5 or September 9 allegations had been reported to state or local agencies. That morning, DSS-F told the inspector she wasn't sure whether NHA-A had updated the police. She also wasn't sure the state agency had been notified. Her explanation: "DSS-F thought NHA-A reported to the state and [NAME]-versa, so neither of them reported it yet."
Neither of them had reported it. Six weeks after a resident told staff she had been walked in on while naked and told a nursing assistant would do nothing for her, no outside agency had been informed.
At 1:05 PM on September 16, DSS-F told the inspector that local agencies had not been informed of either set of allegations, and that she would be calling the police right then. At 1:30 PM, local police arrived at the facility to take a statement from R66.
R66 was out of the building.
The following morning, September 17, the inspector briefed the Director of Nursing, identified as DON-B, on the late reporting for both the August 5 grievance and the September 9 allegations. DON-B's response was direct about what it meant: "The facility was recently cited for this and this is not new, regardless of how we feel about it, we need to report. We have gone over reporting abuse, and we will be educating staff on this."
The facility had been cited for the same failure before.
At 10:01 AM on September 17, the inspector also informed NHA-A of the reporting failures. The inspection report notes that as of the time it was written, no explanation had been received from the facility for why R66's allegations were not reported to local or state agencies in a timely manner.
The deficiency was cited under F0609, which covers the timely reporting of alleged violations involving mistreatment, neglect, and abuse. The level of harm was recorded as minimal harm or potential for actual harm, affecting few residents. The inspection was conducted on September 30, 2025, and the report was printed August 8, 2026.
The facility did take some steps after the August 5 incident. Inspectors reviewed a packet that included a teachable moment form documenting that CNA-X had entered R66's room without knocking. Staff across the unit were asked whether they had ever violated residents' privacy by entering without knocking, and all said no. An education session on bedside manner was completed by all staff. The nursing assistant's conduct, the statement to R66 that she would not provide care for her, was documented in the grievance.
What the packet did not include was a report to the police or to the state.
The gap between what staff understood and what leadership acted on runs through the entire inspection record. The administrative director who filed the grievance called it abuse. DSS-F, when she finally looked at the document with the inspector in the room, agreed it needed to be reported. DON-B told the inspector the facility had already been cited for this exact failure. The knowledge was there. The reporting wasn't.
When police arrived on the afternoon of September 16, prepared to take a statement from a resident who had waited six weeks for anyone outside the building to be told what happened to her, she was gone. The inspection report does not say when she left, where she went, or whether anyone reached her afterward.
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.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
Bayshore Nursing & Rehab in GLENDALE, WI was cited for abuse-related violations during a health inspection on September 30, 2025.
By then, the resident wasn't even in the building.
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.