Bayshore Nursing & Rehab
Open-data reference.
Bayshore Nursing & Rehab is a for profit - limited liability company facility in GLENDALE, WI with 112 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file. Total penalties: $178K.
1300 WEST SILVER SPRING DR, GLENDALE, WI 53209
Phone: 4142288120
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 525371
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 112
- Residents
- 89
- In Hospital
- No
- County
- Milwaukee
- Last Inspection
- Sep 30, 2025
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.34 (nat'l avg: 0.68)
- LPN Hours
- 0.82
- CNA Hours
- 2.25
- Total Nursing Hours
- 3.42 (nat'l avg: 3.89)
- PT Hours
- 0.00
- Nursing Turnover
- 59.6%
- RN Turnover
- 66.7%
What the CMS Record Reveals About Bayshore Nursing & Rehab
Bayshore Nursing & Rehab operates 112 certified beds in GLENDALE, WI with approximately 89 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $178K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.42 total nursing hours per resident day (national average 3.89), with RN coverage at 0.34 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Bayshore Nursing & Rehab falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 59.6%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 12, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 12, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 12, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Category: Administration Deficiencies
Corrected: Nov 12, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 12, 2025
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Nov 12, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Nov 12, 2025
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.
Category: Infection Control Deficiencies
Corrected: Nov 12, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Nov 12, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Nov 12, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 12, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Nov 12, 2025
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Category: Administration Deficiencies
Corrected: Nov 12, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 12, 2025
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 12, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Nov 12, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 12, 2025
Provide routine and 24-hour emergency dental care for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 12, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Nov 12, 2025
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 12, 2025
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 12, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 12, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 12, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 12, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 12, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: Nov 12, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Aug 26, 2025
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 26, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 14, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 26, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 26, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 25, 2025
Provide training in compliance and ethics.
Category: Administration Deficiencies
Corrected: Aug 25, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Category: Infection Control Deficiencies
Corrected: Aug 25, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Category: Administration Deficiencies
Corrected: Aug 25, 2025
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 25, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Category: Resident Rights Deficiencies
Corrected: Aug 25, 2025
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 15.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.8% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.3% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 68.1% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 24.3% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.7% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 18.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 73.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 17.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 7.5% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 21.8% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 25.3% | Yes |
Penalty History 1 penalties totaling $178K
| Date | Type | Amount |
|---|---|---|
| Oct 30, 2024 | Payment Denial | - |
| Mar 21, 2023 | Fine | $178K |
| Mar 21, 2023 | Payment Denial | - |
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Frequently Asked Questions
What is the overall CMS rating for Bayshore Nursing & Rehab?
What are the staffing levels at Bayshore Nursing & Rehab?
How many beds does Bayshore Nursing & Rehab have?
Does Bayshore Nursing & Rehab have any deficiencies on record?
Has Bayshore Nursing & Rehab received any fines or penalties?
Who owns Bayshore Nursing & Rehab?
When was Bayshore Nursing & Rehab last inspected?
What quality measures are tracked for Bayshore Nursing & Rehab?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.