Federal Nursing-Home Survey Record
Bayshore Nursing & Rehab
Does Bayshore Nursing & Rehab have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Bayshore Nursing & Rehab (CCN 525371), in GLENDALE, WI, has federal inspection findings on its record. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related). CMS also lists the facility as a candidate for its Special Focus Facility program; a candidate is not on the active watch list.
In its current inspection cycle, CMS cited the facility for 68 deficiencies; the most serious carries scope/severity L on CMS's A–L scale, a level CMS classifies as Immediate Jeopardy. The most recent federal survey on file is dated 2025-09-30. The dated record below reflects everything CMS publishes for this facility in the current data snapshot. This page restates the federal record as published by CMS and draws no conclusion of its own.
The Federal Record
CMS has flagged this facility with its federal abuse icon.
Below is this facility's federal survey record as on file with CMS.
Federal abuse icon on file
CMS displays its abuse icon for facilities it has cited for resident abuse under its own published methodology (deficiency tag F600 and related). This is the government's own flag, restated here.
A candidate for the federal Special Focus Facility watch list
CMS lists this facility as a candidate for the Special Focus Facility program. It is not on the active watch list.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.0
Deficiency timeline — full federal history
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Provide training in compliance and ethics.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
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.
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide activities to meet all resident's needs.
Observe each nurse aide's job performance and give regular training.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure each resident receives an accurate assessment.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure residents have reasonable access to and privacy in their use of communication methods.
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.
Provide care and assistance to perform activities of daily living for any resident who is unable.
PASARR screening for Mental disorders or Intellectual Disabilities
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Provide routine and 24-hour emergency dental care for each resident.
Respond appropriately to all alleged violations.
Ensure that residents are fully informed and understand their health status, care and treatments.
Provide care or services that was trauma informed and/or culturally competent.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Reasonably accommodate the needs and preferences of each resident.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Post nurse staffing information every day.
Provide enough food/fluids to maintain a resident's health.
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Provide training in compliance and ethics.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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.
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide safe, appropriate pain management for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Respond appropriately to all alleged violations.
Provide and implement an infection prevention and control program.
Document what happened
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