Bayshore Nursing & Rehab
Bayshore Nursing & Rehab in GLENDALE, WI — inspection on September 30, 2025.
Found 39 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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.
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.
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.
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.
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.
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.
entered her room without knocking. [R66] was naked and felt disrespected.
Statements from other residents on the unit asking if they ever felt their privacy was violated by staff entering without knocking, which all documented No.
There was also an education included in the packet which included bedside manner, completed by all staff.
Surveyor reviewed the Documented grievance, dated 8/5/2025, from AD-U, which documented: [R66] said the CNA told [R66] that [CNA-X] will not be doing shit for [R66]. [R66] response was I OK with that.
On 9/11/2025, at 3:32 PM, Surveyor interviewed Director of Social Services (DSS)-F, who indicated that DSS-F and NHA-A, will both review facility investigations to decide if it is reportable. DSS-F stated after interview with R66, that there were no statements from R66 about physical or verbal abuse, per DSS-F interview with R66.
On 9/11/2025, at 3:48 PM, Surveyor interviewed DSS-F, and Surveyor asked about state or local agencies being informed of allegations from 8/5/2025. DSS-F stated, No and indicated that DSS-F didn't know of the full allegations, on 8/5/2025. DSS-F and surveyor reviewed AD-U's grievance document dated 8/5/2025. DSS-F stated that what was documented on this grievance would need to be reported. DSS-F stated this is not the full investigation and DSS-F will give additional information after locating.
On 9/15/2025 11:47 AM, Surveyor interviewed AD-U who stated that this grievance would be considered abuse, and this is why AD-U made sure DSS-F received the documented grievance right away.
On 9/15/2025, Surveyor reviewed the statement from R66 that documented: no one pushed me! dated 9/9/2025.
Surveyor did not observe a report from state or local agencies being informed of the allegations that were reported on 9/9/2025, at 2:29 PM, by Surveyor.
Surveyor was informed on 9/10/2025 by NHA-A, that the facility reported allegations from 9/9/2025 to the state, this was in error.
On 9/16/2025, at 8:40 AM, Surveyor interviewed DSS-F about police notification from 9/9/2025 and DSS-F stated the DSS-F is not sure if NHA-A updated the police. DSS-F indicated that the state agency was also not updated and indicated that DSS-F thought NHA-A reported to the state and [NAME]-versa, so neither of them reported it yet. DSS-F stated the report received from this Surveyor on 9/9/2025, will now be considered reported late.
On 9/16/2025, at 1:05 PM, Surveyor was informed by DSS-F that the local agencies were not informed of allegations from 8/5/2025 or 9/9/2025, and that DSS-F will be calling the police right
525371 09/30/2025
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
F 0609 now.
state and local agencies after R66's allegations of abuse on 8/5/2025.
Surveyor also informed DON-B of reported abuse allegations from Surveyor to NHA-A on 9/9/2025, not being reported. DON-B indicated that 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.
On 9/17/2025, at 10:01 AM, Surveyor informed NHA-A of the concern with reporting.
Surveyor informed NHA-A that R66's allegations on the documented grievance form from 8/5/2025 were not reported timely.
Surveyor informed NHA-A that allegations from R66 to surveyor on 9/9/2025, were also not reported timely.
As of the time of this write up, no additional information was received as to why R66's allegations were not reported timely to local or state agencies.
525371 09/30/2025
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
allegations of verbal abuse on 8/5/2025 and physical abuse on 9/9/2025 being thoroughly
DON-B's expectation that staff thoroughly investigate allegations of abuse. DON-B stated any abuse
On 9/17/2025, at 10:01 AM, Surveyor informed NHA-A, of the concern with thorough investigations of abuse allegations.
Surveyor informed NHA-A that R66's allegations on the documented grievance form from 8/5/2025 were not investigated thoroughly.
Surveyor informed NHA-A that allegations from R66 to surveyor on 9/9/2025, were not thoroughly investigated. NHA-A indicated that the facility did not complete a thorough investigation for R66's allegations. NHA-A stated, We missed that, abuse allegations should be investigated thoroughly.
As of the time of this write up, no additional information was received as to why R66's, allegations of abuse were not thoroughly investigated.
525371 09/30/2025
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
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.
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.
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.
R65 did not have the necessary orders for monitoring mood and behavior. DON-B also acknowledged
09/17/2025 8:30 AM surveyor notified NHA-A and DON-B of concern with R65's lack of assessment,
No other information has been provided at this time.
525371 09/30/2025
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
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.
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.
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.
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.
his cigarette and R40 stated, tosses on ground.
Surveyor asked if anyone steps on the cigarette and
Surveyor observed R40 until R40 tossed their cigarette onto the ground and no staff member was
09/10/2025 at 2:05 PM, Surveyor interviewed Director of Nursing (DON)-B and asked DON-B what practice is followed for supervision while smoking with residents who are cognitively impaired.
DON-B stated, facility does not base smoking supervision on a resident's cognition but rather on the smoking safety assessment.
Surveyor asked how often the smoking safety assessments are completed and DON-B stated, upon resident admission and quarterly.
Surveyor shared with DON-B that there are only 3 smoking safety assessments for R40 dated 11/11/24, 6/24/25 and 8/28/25 with incomplete assessment details/documentation.
Surveyor stated there was not a smoking safety assessment completed upon admission on [DATE] and the first smoking safety assessment occurred on 11/11/24 with 4.5 months lapsing from admission.
The subsequent smoking safety assessment occurred on 6/24/25 with 7 months lapsing in between. DON-B stated the facility is now completing the smoking safety assessments upon admission and quarterly.
Surveyor shared R40 was observed to have a burn hole in their sweatpants and that there was no supervision or a staff member present to ensure R40's cigarette was extinguished.
Surveyor stated, there is a concern R40's care plan is not being followed for smoking interventions. DON-B stated, she understood and is aware R40's care plan is not being followed.
There was no additional information provided at this time.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.