Public Record
Bayshore Nursing & Rehab
Operated by Bedrock Healthcare
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 112
- Avg. residents per day
- 72.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 143
- Fire safety findings
- 51
- Inspections on file
- 17
- Last inspection
- 2025-09-30
*CMS
*CMS
*CMS
*CMS
Citations
143 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0576Generalpotential for harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
- 0584Generalpotential for harm
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.
- 0585Generalpotential for harm
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.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0645Generalpotential for harm
PASARR screening for Mental disorders or Intellectual Disabilities
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0686Seriousimmediate jeopardy
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0700Generalpotential for harm
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.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0761Generalpotential for harm
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.
- 0790Generalpotential for harm
Provide routine and 24-hour emergency dental care for each resident.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0835Seriousimmediate jeopardy
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0887Generalpotential for harm
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.
- 0946Generalpotential for harm
Provide training in compliance and ethics.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0605Generalpotential for harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0727Generalpotential for harm
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.
- 0577Generalno actual harm
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- 0949Generalpotential for harm
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0841Seriousimmediate jeopardy
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0944Generalpotential for harm
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
- 0942Generalpotential for harm
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0945Generalpotential for harm
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0692Seriousimmediate jeopardy
Provide enough food/fluids to maintain a resident's health.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0801Generalpotential for harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0940Generalpotential for harm
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- 0946Generalpotential for harm
Provide training in compliance and ethics.
- 0941Generalpotential for harm
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0584Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0585Generalpotential for harm
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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0584Generalpotential for harm
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.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0837Generalpotential for harm
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0584Generalpotential for harm
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.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0761Generalpotential for harm
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.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0584Generalpotential for harm
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.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0801Generalpotential for harm
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0585Generalpotential for harm
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.
- 0584Generalpotential for harm
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.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0600Seriousactual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0758Generalpotential for harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0744Seriousactual harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0760Seriousactual harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
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.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0691Generalpotential for harm
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0800Generalpotential for harm
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0814Generalno actual harm
Dispose of garbage and refuse properly.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0880Seriousimmediate jeopardy
Provide and implement an infection prevention and control program.
- 0882Seriousimmediate jeopardy
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- 0584Generalpotential for harm
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.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection39 deficiencies
- View inspection reportInspectionFire Safety20 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection4 deficiencies
- View inspection reportInspection15 deficiencies
- View inspection reportInspection9 deficiencies
- View inspection reportInspection6 deficiencies
- View inspection reportInspection4 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection12 deficiencies
Showing the 10 most recent inspections. 7 earlier inspections are also on record.
Ownership
Bedrock Healthcare
9nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Bayshore Nursing & Rehab?
- Bayshore Nursing & Rehab is a Medicare- and Medicaid-certified nursing home in Glendale, WI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 525371.
- What is the CMS rating for Bayshore Nursing & Rehab?
- Bayshore Nursing & Rehab has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Bayshore Nursing & Rehab have?
- Bayshore Nursing & Rehab is certified for 112 beds. It serves an average of 72.9 residents per day.
- How many citations does Bayshore Nursing & Rehab have?
- Bayshore Nursing & Rehab has 143 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Bayshore Nursing & Rehab last inspected?
- Bayshore Nursing & Rehab was last inspected on September 30, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/525371-bayshore-nursing-rehab