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Complaint Investigation

Bayshore Nursing & Rehab

Inspection Date: September 30, 2025
Total Violations 39
Facility ID 525371
Location GLENDALE, WI
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Inspection Findings

F-Tag F0552

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0576

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0576 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Ensure residents have reasonable access to and privacy in their use of communication methods.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0577

Resident Rights Deficiencies
Harm Level: Potential for Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0577 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0582

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0584

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0585

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0605

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-09-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0609 during a complaint investigation conducted on 2025-09-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0610 during a complaint investigation conducted on 2025-09-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Respond appropriately to all alleged violations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0628

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0641

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-09-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0645

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-09-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0656

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0656 during a complaint investigation conducted on 2025-09-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0677

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0679

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide activities to meet all resident's needs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Immediate Jeopardy

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0686

Quality of Life and Care Deficiencies
Harm Level: Immediate Jeopardy

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0689

Quality of Life and Care Deficiencies
Harm Level: Actual Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0699

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0699 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care or services that was trauma informed and/or culturally competent.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0700

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0700 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0727

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-09-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0730

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0730 during a standard health inspection conducted on 2025-09-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0756

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-09-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0761

Pharmacy Service Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-30.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0790

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0790 during a standard health inspection conducted on 2025-09-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide routine and 24-hour emergency dental care for each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0812

Nutrition and Dietary Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-30.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0835

Administration Deficiencies
Harm Level: Immediate Jeopardy

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0835 during a standard health inspection conducted on 2025-09-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Scope/Severity Level L: widespread, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0841

Nursing and Physician Services Deficiencies
Harm Level: Immediate Jeopardy

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0841 during a standard health inspection conducted on 2025-09-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Scope/Severity Level L: widespread, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0842

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-09-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0851

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0851 during a standard health inspection conducted on 2025-09-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0867

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0867 during a standard health inspection conducted on 2025-09-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0880

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0881

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0881 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Implement a program that monitors antibiotic use.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0883

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0887

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-09-30.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0925

Environmental Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0925 during a standard health inspection conducted on 2025-09-30.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0946

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0946 during a standard health inspection conducted on 2025-09-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Provide training in compliance and ethics.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0947

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0947 during a standard health inspection conducted on 2025-09-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

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F-Tag F0949

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Bayshore Nursing & Rehab in GLENDALE, WI for a deficiency under regulatory tag F-F0949 during a standard health inspection conducted on 2025-09-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 39 deficiencies cited during this inspection of Bayshore Nursing & Rehab.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-12.

📋 Inspection Summary

Bayshore Nursing & Rehab in GLENDALE, WI inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDALE, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Bayshore Nursing & Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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