Bayshore Nursing & Rehab
1300 West Silver Spring Dr, Glendale, WI 53209
Bayshore Nursing & Rehab is a nursing home in Glendale, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- not rated by CMS CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (414) 228-8120
- Last standard health inspection
- September 30, 2025 (1 year ago)
- Certified beds
- 112
- Residents per day, on average
- Not listed by CMS
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Bedrock Hcs at Glendale LLC
- Chain
- Bedrock Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (128 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of October 8, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to not rated by CMS.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
4 citations
Health inspection on April 30, 2026
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0600 3 times since 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0657 2 times since 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on May 22, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0689 6 times since 2023.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was SILVER SPRINGS HEALTH CARE CENTER.
CMS update of December 15, 2025
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
Health citation
CMS changed citation F0584 from severity E to F. It is from the health inspection on October 30, 2024. Severity F: potential for more than minimal harm, widespread.
39 citations
Health inspection on September 30, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0835. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on November 12, 2025.
Citation F0841. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
CMS lists it as corrected on November 12, 2025.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0684 4 times since 2023.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 12, 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 12, 2025.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on November 12, 2025.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on November 12, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0880 4 times since 2024.
Citation F0881. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on November 12, 2025.
Citation F0887. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0925 3 times since 2023.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0946 2 times since 2025.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on November 12, 2025.
Citation F0582. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on November 12, 2025.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0585 3 times since 2023.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0641 2 times since 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0656 3 times since 2023.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on November 12, 2025.
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on November 12, 2025.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0756 2 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0761 3 times since 2023.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on November 12, 2025.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on November 12, 2025.
Citation F0576. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on November 12, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0584 8 times since 2023.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on November 12, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0609 4 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0610 2 times since 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on November 12, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on November 12, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0677 2 times since 2023.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on November 12, 2025.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 12, 2025.
Citation F0790. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on November 12, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on November 12, 2025.
Citation F0947. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on November 12, 2025.
CMS has cited this home for F0947 2 times since 2025.
Citation F0577. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
CMS lists it as corrected on November 12, 2025.
20 citations
Fire safety inspection on September 30, 2025
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on December 15, 2025.
Citation E0007. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on January 5, 2026.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 15, 2025.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0291 2 times since 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0345 3 times since 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0353 3 times since 2023.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0355 2 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0712 3 times since 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on December 30, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0918 3 times since 2023.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0271 3 times since 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0321 3 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0363 2 times since 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS has cited this home for K0374 2 times since 2024.
Citation K0225. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0225 2 times since 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0324 3 times since 2023.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on December 15, 2025.
Citation K0541. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0541 2 times since 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0741 2 times since 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for K0920 2 times since 2023.
Payment stopped
August 6, 2025 (1 year ago)
CMS stopped payment for new admissions from August 6, 2025, for 100 days.
1 citation
Health inspection on July 30, 2025
CMS lists this as a complaint inspection.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for F0558 2 times since 2024.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
4 citations
Health inspection on July 28, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 14, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 26, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 26, 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on August 26, 2025.
15 citations
Health inspection on July 3, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0692. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 14, 2025.
CMS has cited this home for F0692 3 times since 2023.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on August 25, 2025.
CMS has cited this home for F0801 2 times since 2023.
Citation F0940. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on August 25, 2025.
Citation F0941. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on August 25, 2025.
Citation F0942. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on August 25, 2025.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on August 25, 2025.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on August 25, 2025.
Citation F0945. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on August 25, 2025.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on August 25, 2025.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on August 25, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 25, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 25, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 29, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on August 25, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on August 25, 2025.
CMS has cited this home for F0755 3 times since 2023.
9 citations
Health inspection on May 29, 2025
CMS lists this as a complaint inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 27, 2025.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on June 27, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 27, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on June 27, 2025.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on June 27, 2025.
CMS has cited this home for F0655 2 times since 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 27, 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 27, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 27, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on June 27, 2025.
CMS has cited this home for F0695 2 times since 2023.
Fine
May 29, 2025 (1 year ago)
CMS fine of $424,350 on May 29, 2025.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of March 26, 2025
CMS abuse icon
CMS added its abuse icon to this home.
6 citations
Health inspection on January 29, 2025
CMS lists this as a complaint inspection.
Citation F0584. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on February 27, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on February 27, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on February 27, 2025.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 27, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 27, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 27, 2025.
CMS has cited this home for F0759 2 times since 2023.
Payment stopped
January 22, 2025 (1 year ago)
CMS stopped payment for new admissions from January 22, 2025, for 36 days.
4 citations
Health inspection on October 30, 2024
CMS lists this as a complaint inspection.
Citation F0584. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on February 27, 2025.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on December 2, 2024.
CMS has cited this home for F0814 3 times since 2023.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on December 2, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 2, 2024.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.3 to 2.9 hours per resident per day.
Fine
CMS changed the fine from December 1, 2021 from $16,121 to $16,750.
CMS update of August 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of July 31, 2024
Fine
CMS changed the fine from March 21, 2023 from $173,570 to $178,395.
1 citation
Health inspection on July 24, 2024
CMS lists this as a complaint inspection.
Citation F0837. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on August 15, 2024.
CMS update of June 26, 2024
Fine
CMS changed the fine from December 1, 2021 from $15,000 to $16,121.
12 citations
Health inspection on June 20, 2024
CMS lists this as a standard inspection and a complaint inspection.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on July 25, 2024.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 25, 2024.
Citation F0908. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on July 25, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 25, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 25, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 25, 2024.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on July 25, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 25, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 25, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 25, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 25, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on July 25, 2024.
16 citations
Fire safety inspection on June 20, 2024
CMS lists this as a standard inspection.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 19, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 19, 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 19, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 21, 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on August 19, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 19, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on August 19, 2024.
CMS has cited this home for K0222 2 times since 2023.
Citation K0232. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on July 25, 2024.
Citation K0233. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install resident room doors of proper design and width.
CMS lists it as corrected on July 25, 2024.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on August 19, 2024.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 19, 2024.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 19, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on August 19, 2024.
Citation K0225. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on June 18, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 19, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on July 25, 2024.
3 citations
Health inspection on May 30, 2024
CMS lists this as a complaint inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 16, 2024.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on June 16, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 16, 2024.
CMS update of March 28, 2024
Fine
CMS changed the fine from March 21, 2023 from $267,030 to $173,570.
8 citations
Health inspection on October 10, 2023
CMS lists this as a complaint inspection.
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on November 7, 2023.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on November 7, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 7, 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 7, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 7, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 7, 2023.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on November 7, 2023.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on November 7, 2023.
22 citations
Health inspection on March 21, 2023
CMS lists this as a standard inspection.
Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
22 of 323 Wisconsin homes (7%) got a citation at the immediate jeopardy level in 2023.
Citation F0882. Severity L: immediate jeopardy, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on May 17, 2023.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 24, 2023.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 13, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 17, 2023.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on May 17, 2023.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 17, 2023.
Citation F0800. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
CMS lists it as corrected on May 17, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 17, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on May 17, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 17, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 17, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on May 17, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 17, 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 13, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 17, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on May 17, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 13, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 17, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 17, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 17, 2023.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on May 17, 2023.
Citation F0814. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on May 17, 2023.
15 citations
Fire safety inspection on March 21, 2023
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 19, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 19, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 19, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 19, 2023.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on April 19, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 19, 2023.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on April 19, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 19, 2023.
Citation K0541. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on April 19, 2023.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on April 19, 2023.
Citation K0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on April 19, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 19, 2023.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on April 19, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 19, 2023.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on April 19, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHOPP, LYNN5% or greater indirect ownership interest · 17% · since 10/01/2019
- CHOPP, MARTIN5% or greater indirect ownership interest · 18% · since 10/01/2019
- CHOPP, PNINA5% or greater indirect ownership interest · 18% · since 10/01/2019
- CHOPP, RACHEL5% or greater indirect ownership interest · 7% · since 10/01/2019
- CHOPP, SARAH5% or greater indirect ownership interest · 5% · since 10/01/2019
- CHOPP, SOLOMON5% or greater indirect ownership interest · 10% · since 10/01/2019
- PRAGER, AVROHOM5% or greater indirect ownership interest · 13% · since 10/01/2019
- PRAGER, SHULAMIT5% or greater indirect ownership interest · 13% · since 10/01/2019
- OPAL HEALTHCARE NJ LLCOperational/managerial control · not applicable · since 10/01/2019
- NICHOLS, KENNETHOperational/managerial control · not applicable · since 10/01/2019
Questions
When was Bayshore Nursing & Rehab last inspected?
CMS lists September 30, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Bayshore Nursing & Rehab have?
CMS lists 128 health citations since March 21, 2023. CMS also calls these deficiencies.
Has Bayshore Nursing & Rehab been fined?
CMS lists 1 fine in the past three years, $424,350 in total.
What is the CMS star rating of Bayshore Nursing & Rehab?
Its CMS overall star rating is 1 of 5.
Is Bayshore Nursing & Rehab a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.