Inspection visit
Health inspection
Citations
39 citations recorded*CMS
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.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F584 - Safe Environment
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.
F585 - Grievances
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.
F628 - Documentation
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F700 - Bed Rails
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.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F761 - Labeling of Drugs and Biologicals
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.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
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.
F946 - Compliance and ethics
Provide training in compliance and ethics.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F841 - Medical director
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F949 - Training Requirements
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
FAQ · About this visit
Common questions about this visit
What happened during the September 30, 2025 survey of Bayshore Nursing & Rehab?
This was a inspection survey of Bayshore Nursing & Rehab on September 30, 2025. The surveyor cited 39 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Bayshore Nursing & Rehab on September 30, 2025?
Yes, 39 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.