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Bayshore Nursing & Rehab

GLENDALE, WI · Milwaukee County · For profit - Limited Liability company · 112 certified beds

📍 1300 West Silver Spring Dr, Glendale, WI 53209  ·  📞 (414) 228-8120

Medicare ID: 525371  ·  Last Medicare inspection: Sep 30, 2025

Consumer Alert: Abuse Citation
This facility has been cited for potential issues related to abuse. CMS places this warning on facilities where inspectors identified concerns during their survey.
Special Focus Facility (SFF)
CMS has identified this as a facility with a history of serious quality issues that requires enhanced oversight and more frequent inspections.
Overall Safety Score
45
out of 100
Serious Concerns
Component Scores
Inspection
66
Staffing
✓ Clean
Enforcement
Complaints
59
Quality
📋 Last inspected: September 30, 2025 📦 CMS data as of: May 2026

Score Breakdown

Inspection
0
Staffing
66
Enforcement
100
Complaints
0
Quality Outcomes
59

What the numbers mean

Bayshore Nursing & Rehab scored 45 out of 100 — 22 points below the state average of 67.

📋 Inspections: 150 citations over the last 36 months — 112 more than the state average (38). 11 were rated serious (G+) — inspectors found actual or potential harm to residents. 53 findings recurred across inspection cycles — indicating a problem that was not fixed.

👥 Staffing: Staffing is within an acceptable range but not among the highest-performing facilities. Ask about nurse coverage on evenings, nights, and weekends when you visit.

⚖️ Penalties & enforcement: No significant federal fines or enforcement actions on record — a positive indicator of consistent regulatory compliance.

⚠️ Complaints: Above-average complaint activity. Complaint surveys are unannounced and targeted — they often surface problems that routine annual inspections miss. Ask management about the nature of complaints filed and how each was resolved.

⚠️ Resident quality outcomes: Some quality measures are below national benchmarks. Areas like fall prevention, pain management, or medication use may warrant closer attention.

🔍 Most cited areas: The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks., The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.. The full report provides the complete citation record with dates, severity levels, and plain-English descriptions.

What inspectors found (last 3 surveys)

150
Total citations
State avg: 38.3
11
Serious (G+)
State avg: 1.8
53
Repeat findings

Top concern areas

121
6
Electrical & Utility Safety
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
5
Fire Doors & Corridors
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.

⚖ Penalties & Enforcement

Federal civil monetary penalties (CMPs) are only issued after a facility has failed two levels of regulatory review — meaning problems were found on inspection and the facility could not rebut the findings. This is a serious escalation beyond a standard citation.

No federal penalties on record. CMS has not issued civil monetary penalties or payment denials against this facility in the current reporting period.
📋 Enforcement Context Analysis
Clean enforcement record — No significant federal enforcement actions or fines on record for this facility. This is a positive indicator.
✅ No enforcement actions on record. This facility's enforcement score of 100/100 reflects a clean enforcement history in the current CMS reporting cycle.

📅 Per-action enforcement records (date, fine amount, and penalty type for each individual action) are sourced from a separate CMS enforcement dataset and will be added in a future data update.

🩹

Resident Wellbeing — Key Indicators

These are the measures families ask about most. They come from CMS clinical assessments of every resident — not just inspection reports. Stars (★) count toward the official CMS quality star rating.

Antipsychotic medication use
1.2% lower is better
Share of long-stay residents given antipsychotic drugs. High use can signal residents being over-medicated rather than receiving attentive care.
Flu vaccination rate
12.5% higher is better
Share of long-stay residents vaccinated against the flu this season. Higher is better.
Re-hospitalized after discharge
56.7% lower is better
How often short-stay residents who went home ended up back in the hospital within 30 days. Risk-adjusted for resident health.
Hospitalization rate
8.8% lower is better
How often long-stay residents were hospitalized over the past year. Adjusted for how sick residents were.

Source: CMS MDS Quality Measures & Medicare claims data. Scores shown are the most recent 4-quarter averages for long-stay residents.

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What to know about Bayshore Nursing & Rehab

Bayshore Nursing & Rehab is a Medicare-certified nursing home in Glendale, Wi with 112 certified beds. Its current Senior Care Report Card score is 45/100, placing it in the Serious Concerns range. The latest CMS survey date in our data is Sep 30, 2025. Over the last 36 months, our CMS citation data shows 150 citations, including 11 serious findings and 53 repeat findings. Families comparing this facility should pay close attention to inspection history, complaint activity before scheduling a tour or accepting placement. Ownership type on file: For profit - Limited Liability company.

⚠️
Overall Assessment — Serious Concerns  ·  45/100
This facility has notable issues in the federal inspection record that require careful evaluation.
What to do next: Do not choose without thoroughly reviewing all citations below and getting answers in writing from management.
🛑
CMS Special Focus Facility
CMS has placed this facility on its Special Focus Facility list — a designation reserved for nursing homes with a persistent pattern of serious problems and substandard care. These facilities receive more frequent inspections and are under enhanced federal oversight. This is one of the most serious designations a nursing home can receive.
👥
Staffing Below Federal Minimum Standards
This facility provides 0.51 RN hours per resident per day — below the CMS minimum of 0.75 hours. Total nurse staffing is 4.01 hours per resident per day. Understaffing is the strongest predictor of poor inspection outcomes. Ask specifically about RN coverage on evenings, nights, and weekends.

What this facility's data shows

📋 Inspections
Inspection record is well below average. Multiple or serious deficiencies found.
👥 Staffing
Staffing is in an acceptable range but below the highest-performing facilities.
⚖ Penalties
No significant federal enforcement actions or fines in the record.
💬 Complaints
Higher-than-average complaint volume. Complaint surveys are often triggered by serious resident concerns.
Quality outcomes are acceptable overall but some measures are below benchmarks. See the How Are Residents Doing section.
⚠ Serious Findings on Record: 15 citation(s) where inspectors found actual harm or immediate jeopardy to residents. See Section D for the full details and ask management how each was resolved.
Score breakdown — the numbers behind this assessment
👥 Staffing 66
What it measures RN hours per resident per day, total nurse hours, and RN turnover rate.
💡 Understaffing is the strongest single predictor of poor inspection outcomes.
📋 Inspection 0
What it measures Number, severity (A–L), and scope of deficiencies found. Repeat findings carry extra weight.
💡 Every citation in Section D feeds directly into this score.
⚖ Penalties 100
What it measures Whether CMS escalated from a deficiency citation to actual financial or operational sanctions.
💡 A penalty means the facility already failed a second level of regulatory review.
💬 Complaints 0
What it measures Volume of complaint-triggered inspections and the share that were substantiated.
💡 Complaint surveys are unannounced — they often surface issues annual surveys miss.
🎯 Quality outcomes 59
What it measures Resident outcome measures: falls, pressure ulcers, antipsychotic use, weight loss, hospitalizations.
💡 Reflects the lived experience of residents beyond what inspectors observe.

Each pillar scores 0–100 and is combined into the overall score. A strong overall can mask a weak pillar — compare all four and see how they stack against the state average in Section B.

🏗 How This Facility Compares to WI State Averages

Comparing a facility to others in the same state puts its score in context. A facility might have 8 citations and that could be above average in one state and below in another. Green means this facility is doing better than its peers; red means it's falling short.

Metric This facility WI avg vs. State
Overall score
The combined Senior Care Report Card score out of 100.
45 67 ▼ Worse than state avg
Inspection score
How well the facility performs on standard health surveys.
0 52 ▼ Worse than state avg
Staffing score
RN hours, total nurse hours, and staff turnover from CMS payroll data.
66 75 ▼ Worse than state avg
Penalty score
Fines, payment denials, and enforcement actions on file.
100 69 ▲ Better than state avg
Complaint score
Volume of complaint surveys and substantiated complaints.
0 81 ▼ Worse than state avg
Quality score
Resident clinical outcomes vs national benchmarks: falls, antipsychotics, pain, vaccination, hospitalizations.
59 57 ▲ Better than state avg
Citations (3 yrs)
Total number of deficiencies cited in the last 36 months.
150 38.3 ▼ Worse than state avg
Serious citations
Citations rated severity G or higher (actual harm or immediate jeopardy).
11 1.8 ▼ Worse than state avg

📅 Inspection Timeline

State health inspectors visit nursing homes on a regular cycle — typically every 12 to 15 months — and document every deficiency they find. The timeline below shows the date and scale of each inspection visit over the past several years. A pattern of worsening surveys is a red flag even if the most recent visit looks clean.

2025-09-30
59 citations  (5 serious)
2025-07-30
1 citations
2025-07-28
4 citations  (1 serious)
2025-07-03
15 citations  (1 serious)
2025-05-29
9 citations
2025-01-29
6 citations
2024-10-30
4 citations
2024-07-24
1 citations
2024-06-20
28 citations
2024-05-30
3 citations

Bar length proportional to citation count. Red = serious findings (severity G+). Orange = elevated. Green = low.

📄 Full Citation Record

Every time state inspectors visit a nursing home, they write up anything that doesn’t meet federal standards. Each write-up is called a citation.

Each citation shows what the problem was and how serious it was, using a color-coded badge:

Confused by codes like F0732 or K0363? Use the free inspection report decoder to understand F-tags, fire-safety K-tags, severity letters, and repeat findings. Get the decoder →
Green — No residents harmed Yellow — Risk of harm, no injury Orange — A resident was harmed Red — Life or safety in danger

A Repeat tag means the same problem appeared in a previous inspection — it was not fully corrected the first time. Citations shown cover the last two years.

Survey: 2025-09-30 59 citation(s) — 5 serious
F0841 Immediate danger
Responsibilities of facility
F0835 Immediate danger
F0835
F0684 Immediate danger
Quality of care
F0686 Immediate danger
Pressure ulcer prevention & treatment
F0689 Resident was harmed
Accident & hazard prevention
F0867 No harm, could worsen
Quality assurance program
K0345 No harm, could worsen
Fire safety: fire alarm testing and maintenance
The facility had a problem with fire alarms, smoke detectors, alarm testing, or alarm outage procedures. These systems warn staff and residents when fire or smoke is detected.
K0914 No harm, could worsen
Electrical safety: outlets, wiring and equipment maintenance
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
F0727 No harm, could worsen
Physician visits & orders
F0881 No harm, could worsen
Infection preventionist qualifications
K0291 No harm, could worsen
Fire safety: hazardous areas must be protected
The facility did not fully protect higher-risk rooms or equipment areas, such as storage, laundry, kitchens, or other spaces where fire could start or spread faster.
K0918 No harm, could worsen
Electrical safety: essential electrical system maintenance
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
E0039 No harm, could worsen
E0039
F0946 No harm, could worsen
Staff training requirements
F0949 No harm, could worsen
F0949
K0353 No harm, could worsen
Fire safety: sprinkler system maintenance and testing
The facility had a problem with sprinkler coverage, maintenance, testing, or outage procedures. Sprinklers are a key fire-protection system that help control fires before residents are in danger.
F0851 No harm, could worsen
F0851
F0812 No harm, could worsen
Food sanitation & safety
F0880 No harm, could worsen
Infection prevention & control
E0004 No harm, could worsen
E0004
K0712 No harm, could worsen
Fire safety: fire drills and staff preparedness
The facility had a problem with fire drills, evacuation planning, staff preparedness, or documentation showing that staff know what to do in an emergency.
K0355 No harm, could worsen
Fire safety: portable fire extinguishers
Fire safety: portable fire extinguishers. This is a building, fire protection, emergency preparedness, or electrical-safety issue found during a CMS life-safety inspection. Families should ask what was repaired, when it was corrected, and whether staff were retrained.
F0887 No harm, could worsen
F0887
F0925 No harm, could worsen
F0925
E0007 No harm, could worsen
E0007
K0321 No harm, could worsen
Fire safety: hazardous rooms and storage areas
The facility did not fully protect higher-risk rooms or equipment areas, such as storage, laundry, kitchens, or other spaces where fire could start or spread faster.
F0679 No harm, could worsen
Activities program
F0756 No harm, could worsen
Drug regimen review
F0582 No harm, could worsen
F0582
F0585 No harm, could worsen
Right to file a grievance
F0656 No harm, could worsen
Comprehensive care plan
F0883 No harm, could worsen
Immunizations (flu & pneumonia)
F0641 No harm, could worsen
Accuracy of resident assessment
K0271 No harm, could worsen
Fire safety: discharge from exits
The facility had a problem with exits, stairways, emergency lighting, or evacuation routes that residents and staff may need during a fire or emergency.
F0730 No harm, could worsen
Specialist consultant services
K0363 No harm, could worsen
Fire safety: corridor doors must close and latch
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.
F0761 No harm, could worsen
Medication storage & labeling
K0374 No harm, could worsen
Fire safety: smoke barrier doors must close properly
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.
F0790 No harm, could worsen
Dental services
K0225 No harm, could worsen
Fire safety: stairs and exit enclosures
The facility had a problem with exits, stairways, emergency lighting, or evacuation routes that residents and staff may need during a fire or emergency.
F0842 No harm, could worsen
Medical records accuracy & security
F0699 No harm, could worsen
F0699
K0741 No harm, could worsen
Fire safety: smoking rules and fire-safe ash disposal
The facility had a problem with fire drills, evacuation planning, staff preparedness, or documentation showing that staff know what to do in an emergency.
F0584 No harm, could worsen
F0584
F0576 No harm, could worsen
F0576
K0541 No harm, could worsen
K0541
Fire and life safety requirement. This is a building, fire protection, emergency preparedness, or electrical-safety issue found during a CMS life-safety inspection. Families should ask what was repaired, when it was corrected, and whether staff were retrained.
F0552 No harm, could worsen
Right to be informed of care choices
F0677 No harm, could worsen
Personal hygiene & grooming assistance
F0609 No harm, could worsen
Timely reporting of alleged violations
F0610 No harm, could worsen
Investigate & correct violations
F0947 No harm, could worsen
Nurse aide training program
K0511 No harm, could worsen
Fire safety: gas, electric and utility systems
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
F0628 No harm, could worsen
F0628
F0645 No harm, could worsen
BHP referral requirements
K0324 No harm, could worsen
Fire safety: cooking equipment and kitchen protection
The facility did not fully protect higher-risk rooms or equipment areas, such as storage, laundry, kitchens, or other spaces where fire could start or spread faster.
F0700 No harm, could worsen
Side rail safety
F0605 No harm, could worsen
F0605
K0920 No harm, could worsen
Electrical safety: power strips and extension cords
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
F0577 No harm
F0577
Survey: 2025-07-30 1 citation(s)
F0558 No harm, could worsen
Reasonable accommodations
Survey: 2025-07-28 4 citation(s) — 1 serious
F0689 Immediate danger
Accident & hazard prevention
F0600 No harm, could worsen
Freedom from abuse, neglect & exploitation
F0609 No harm, could worsen
Timely reporting of alleged violations
F0732 No harm
Pharmacy policies & procedures
Nursing or clinical staff did not follow accepted professional standards when delivering care, which can put residents at risk for preventable complications.
Survey: 2025-07-03 15 citation(s) — 1 serious
F0692 Immediate danger
Nutrition & hydration status
F0943 No harm, could worsen
F0943
F0941 No harm, could worsen
F0941
F0942 No harm, could worsen
F0942
F0801 No harm, could worsen
Qualified dietary staff
F0944 No harm, could worsen
F0944
F0940 No harm, could worsen
F0940
F0945 No harm, could worsen
F0945
F0947 No harm, could worsen
Nurse aide training program
F0946 No harm, could worsen
Staff training requirements
F0610 No harm, could worsen
Investigate & correct violations
F0609 No harm, could worsen
Timely reporting of alleged violations
F0755 No harm, could worsen
Pharmaceutical services
F0697 No harm, could worsen
Pain management
F0684 No harm, could worsen
Quality of care
Survey: 2025-05-29 9 citation(s)
F0880 No harm, could worsen
Infection prevention & control
F0684 No harm, could worsen
Quality of care
F0657 No harm, could worsen
Care plan timing & review
F0655 No harm, could worsen
Baseline care plan
F0690 No harm, could worsen
Bowel & bladder care
F0695 No harm, could worsen
Respiratory care
F0584 No harm, could worsen
F0584
F0561 No harm, could worsen
Grievance process
F0641 No harm, could worsen
Accuracy of resident assessment
Survey: 2025-01-29 6 citation(s)
F0584 No harm, could worsen
F0584
F0755 No harm, could worsen
Pharmaceutical services
F0554 No harm, could worsen
Right to refuse treatment
F0585 No harm, could worsen
Right to file a grievance
F0759 No harm, could worsen
Medication error rate control
F0580 No harm, could worsen
Notification of change in condition
Survey: 2024-10-30 4 citation(s)
F0584 No harm, could worsen
F0584
F0925 No harm, could worsen
F0925
F0814 No harm, could worsen
F0814
F0600 No harm, could worsen
Freedom from abuse, neglect & exploitation
Survey: 2024-07-24 1 citation(s)
F0837 No harm, could worsen
F0837
Survey: 2024-06-20 28 citation(s)
K0712 No harm, could worsen
Fire safety: fire drills and staff preparedness
The facility had a problem with fire drills, evacuation planning, staff preparedness, or documentation showing that staff know what to do in an emergency.
F0814 No harm, could worsen
F0814
F0880 No harm, could worsen
Infection prevention & control
K0521 No harm, could worsen
Fire safety: fire pump inspection and testing
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
K0345 No harm, could worsen
Fire safety: fire alarm testing and maintenance
The facility had a problem with fire alarms, smoke detectors, alarm testing, or alarm outage procedures. These systems warn staff and residents when fire or smoke is detected.
K0761 No harm, could worsen
Fire safety: inspection and testing documentation
The facility had a problem with fire drills, evacuation planning, staff preparedness, or documentation showing that staff know what to do in an emergency.
K0324 No harm, could worsen
Fire safety: cooking equipment and kitchen protection
The facility did not fully protect higher-risk rooms or equipment areas, such as storage, laundry, kitchens, or other spaces where fire could start or spread faster.
K0918 No harm, could worsen
Electrical safety: essential electrical system maintenance
The facility had a problem with electrical systems, emergency power, outlets, power strips, generators, utilities, or medical gas handling. These issues can create fire or emergency-response risks.
F0908 No harm, could worsen
Essential equipment & supplies
K0233 No harm, could worsen
K0233
Fire and life safety requirement. This is a building, fire protection, emergency preparedness, or electrical-safety issue found during a CMS life-safety inspection. Families should ask what was repaired, when it was corrected, and whether staff were retrained.
K0353 No harm, could worsen
Fire safety: sprinkler system maintenance and testing
The facility had a problem with sprinkler coverage, maintenance, testing, or outage procedures. Sprinklers are a key fire-protection system that help control fires before residents are in danger.
K0363 No harm, could worsen
Fire safety: corridor doors must close and latch
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.
K0222 No harm, could worsen
Fire safety: exit doors must open properly
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.
K0271 No harm, could worsen
Fire safety: discharge from exits
The facility had a problem with exits, stairways, emergency lighting, or evacuation routes that residents and staff may need during a fire or emergency.
K0232 No harm, could worsen
K0232
Fire and life safety requirement. This is a building, fire protection, emergency preparedness, or electrical-safety issue found during a CMS life-safety inspection. Families should ask what was repaired, when it was corrected, and whether staff were retrained.
F0584 No harm, could worsen
F0584
K0374 No harm, could worsen
Fire safety: smoke barrier doors must close properly
The facility had a problem with corridor doors, smoke doors, or hallway barriers that are supposed to slow smoke and fire spread so residents have time to evacuate or shelter safely.
F0558 No harm, could worsen
Reasonable accommodations
F0656 No harm, could worsen
Comprehensive care plan
K0355 No harm, could worsen
Fire safety: portable fire extinguishers
Fire safety: portable fire extinguishers. This is a building, fire protection, emergency preparedness, or electrical-safety issue found during a CMS life-safety inspection. Families should ask what was repaired, when it was corrected, and whether staff were retrained.
F0919 No harm, could worsen
F0919
F0689 No harm, could worsen
Accident & hazard prevention
F0692 No harm, could worsen
Nutrition & hydration status
F0578 No harm, could worsen
F0578
F0607 No harm, could worsen
Abuse & neglect prevention policies
K0225 No harm, could worsen
Fire safety: stairs and exit enclosures
The facility had a problem with exits, stairways, emergency lighting, or evacuation routes that residents and staff may need during a fire or emergency.
F0761 No harm, could worsen
Medication storage & labeling
K0321 No harm, could worsen
Fire safety: hazardous rooms and storage areas
The facility did not fully protect higher-risk rooms or equipment areas, such as storage, laundry, kitchens, or other spaces where fire could start or spread faster.
🩹

How Are Residents Doing?

Inspections tell you whether a facility followed the rules. These measures tell you how residents actually fared — whether they fell, experienced pain, lost weight, or were over-medicated. CMS collects this data through regular clinical assessments that nurses complete for every resident. Unlike inspections, which happen once a year, these assessments happen continuously.

⚠ Attention: 2 of 8 star-rated measures show rates above what\'s typically considered acceptable. This means the facility may be struggling in areas that directly affect residents\' day-to-day wellbeing — not just its inspection record.

How to read these cards: Each card shows one measure. Lower percentages are better for most (e.g. fewer falls), but higher is better for vaccination rates and community return. ★ Star rating marks measures CMS uses in its official quality star rating.

Long Stay Residents — 2025Q1-2025Q4
★ Star rating
Daily activity decline
19.6% lower is better
Share of long-stay residents who lost the ability to dress, eat, or move around independently over the past year. Rising rates can signal that residents aren't receiving enough physical therapy or that staffing is too thin to support mobility.
★ Star rating
Urinary tract infections
1.0% lower is better
Share of long-stay residents who had a urinary tract infection. While some UTIs are unavoidable, high rates can point to poor hydration practices, catheter hygiene, or rushed care routines.
★ Star rating
Antipsychotic medication use
1.2% lower is better
Share of long-stay residents given antipsychotic drugs. These medications carry serious risks for older adults. High use often signals that a facility is medicating residents to manage behavior instead of addressing needs through attentive, person-centered care.
★ Star rating
Percentage of long-stay residents experiencing on…
5.5% lower is better
Percentage of long-stay residents experiencing one or more falls with major injury
★ Star rating
Flu vaccination rate
12.5% higher is better
Share of long-stay residents vaccinated against the flu. Nursing homes are high-risk environments for flu outbreaks. Anything below 90% warrants a question about the facility's vaccination policy.
★ Star rating
Percentage of long-stay residents with pressure u…
7.7% lower is better
Percentage of long-stay residents with pressure ulcers
★ Star rating
Percentage of long-stay residents who received an…
26.6% lower is better
Percentage of long-stay residents who received an antipsychotic medication
Physical restraints used
8.0% lower is better
Share of long-stay residents physically restrained (lap belts, side rails). Federal regulations require restraints to be a last resort. High use is a red flag for understaffed facilities cutting corners on behavioral care.
Signs of depression
0.0% lower is better
Share of long-stay residents showing symptoms of depression. Social isolation, lack of meaningful activities, and poor staffing all contribute. This measure reflects the emotional quality of life inside the facility.
Unexplained weight loss
0.3% lower is better
Share of long-stay residents who lost 5% or more of body weight unexpectedly. This can indicate inadequate nutrition, difficulty eating without assistance, or unaddressed medical issues.
Percentage of long-stay residents assessed and ap…
67.9% lower is better
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
Pneumonia vaccination rate
19.5% higher is better
Share of long-stay residents vaccinated against pneumococcal pneumonia — one of the leading causes of death in older adults. Higher is better.
Percentage of long-stay residents assessed and ap…
73.0% lower is better
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
Percentage of long-stay residents with new or wor…
24.6% lower is better
Percentage of long-stay residents with new or worsened bowel or bladder incontinence
Short Stay Residents — 2025Q1-2025Q4
★ Star rating
Worsening depression symptoms
1.8% lower is better
Share of long-stay residents whose depression got measurably worse over the past year — despite being in a care facility.
Percentage of short-stay residents assessed and a…
23.5% lower is better
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
Emergency room visits (short-stay)
17.9% lower is better
Share of short-stay residents sent to the ER during their recovery stay. ER visits are disruptive for recovering patients and sometimes avoidable with better on-site clinical management.

Source: CMS MDS Quality Measures (2025Q1-2025Q4). Collected via standardized clinical assessments — not inspector visits.

🏥

Hospitalization & ER Visits

These numbers come directly from Medicare claims — real billing records of every time a resident was hospitalized or sent to the emergency room. They\'re among the most objective measures of care quality because they can\'t be influenced by how a facility writes up an assessment. The adjusted score is the most meaningful number — it\'s been corrected to account for how sick residents were, so a facility treating frailer patients isn\'t unfairly penalized.

What to look for: An adjusted score significantly above the expected score means this facility hospitalizes residents more often than peer facilities with similar patient populations — that gap is worth asking about directly.

Short Stay Residents — 20241001-20250930
★ Star rating
Re-hospitalized after going home
56.7% risk-adjusted rate
Actual: 60.0% Expected: 25.3%
▲ Higher than expected — worth asking about
How often short-stay residents who went home ended up back in the hospital within 30 days. A high rate suggests residents were discharged before they were ready, or that the facility didn't coordinate follow-up care well. Risk-adjusted so facilities treating sicker residents aren't unfairly penalized.
★ Star rating
Hospitalization rate (long-stay)
8.8% risk-adjusted rate
Actual: 10.0% Expected: 12.6%
✓ Better than expected for similar residents
How often long-stay residents were hospitalized over the past year, adjusted for how ill they were. A high rate relative to expectations suggests the facility may be sending residents to the hospital for issues that skilled nursing staff should be able to manage on-site.
Long Stay Residents — 20241001-20250930
★ Star rating
Number of hospitalizations per 1000 long-stay res…
3.9% risk-adjusted rate
Actual: 4.3% Expected: 2.1%
▲ Higher than expected — worth asking about
Number of hospitalizations per 1000 long-stay resident days
★ Star rating
Number of outpatient emergency department visits …
3.2% risk-adjusted rate
Actual: 3.4% Expected: 1.8%
About the same as similar facilities
Number of outpatient emergency department visits per 1000 long-stay resident days

Source: CMS Medicare claims data. Scores are risk-adjusted — they account for how ill residents were when admitted so facilities treating sicker populations aren\'t penalized for it.

💬 Questions to Ask Before Touring

These questions are generated specifically from this facility's score profile and citation history — not a generic checklist. A facility's willingness to answer them openly, and the quality of their answers, is itself an important signal. Bring this list when you tour or call.

  1. Federal inspectors found 15 citations rated as causing actual harm or immediate jeopardy in the public record. Walk us through each incident: what happened, who was affected, and what specific policy or staffing changes have been put in place since?
  2. What is your current RN-to-resident ratio on each shift, and what is your annual staff turnover rate among nursing staff?
  3. Complaint data shows a higher-than-average volume of formal complaints filed with the state. What were the most common categories last year, and how does your resolution process work from the moment a complaint is filed?
  4. Some resident outcome measures are below average here. What is your current approach to fall prevention, pain management, and quarterly medication review?
  5. 15 citations in the public record were rated as causing actual harm to a resident. Can you describe what occurred in each case and what specific safeguards are now in place?
  6. Can we speak privately with two or three current residents or their families?

👪 Family Decision Guide

This guide translates this facility's data into practical next steps for families. It is not a recommendation for or against placement — it is a structured framework for the conversations you need to have before making a decision.

✓ Positives to confirm

  • No significant penalty history — a positive indicator of consistent compliance
  • No pattern of repeat violations detected

⚠ Areas to probe

  • Inspection score is low — ask for the most recent state survey results
  • Elevated complaint activity — ask how resident concerns are investigated
  • Serious-harm citations on record — require a written explanation of corrective action
  • Always speak with at least two current residents or family members independently

📈 Score History

The score is recalculated every time CMS releases updated data (typically monthly). A consistent downward trend is more concerning than a single low score. An improving trend after a period of poor performance may indicate management changes are taking effect. Use the free facility-watch form above to get email alerts when this facility's record changes materially.

2026-05-27
45 — Concerning

🏢 Ownership & Operators

Ownership matters because large corporate chains sometimes prioritize cost controls over care quality. CMS requires every nursing home to disclose its owners, operators, and managing employees. Frequent ownership changes can disrupt staffing and operations — which is why we flag facilities that changed ownership in the past 12 months.

🔗 CHOPP, LYNN operates 3 facilities across WI.
Owner / Operator Role Ownership % Effective
CHOPP, LYNN Individual 1970-01-01
CHOPP, SARAH Individual 1970-01-01
NICHOLS, KENNETH Individual 1970-01-01
CHOPP, SOLOMON Individual 1970-01-01
OPAL HEALTHCARE NJ LLC Organization 1970-01-01
PRAGER, AVROHOM Individual 1970-01-01
CHOPP, MARTIN Individual 1970-01-01
CHOPP, PNINA Individual 1970-01-01
CHOPP, RACHEL Individual 1970-01-01
PRAGER, SHULAMIT Individual 1970-01-01
BEDROCK HC WI LLC Organization 1970-01-01

🔔 Monthly tracking is now free

We check CMS data monthly. Use the tracking form above and we will email you when new citations appear, scores change, or enforcement actions are added.

📋
Monthly report update
New citation alerts
📈
Score trend tracking
🏠 Verify this data on Medicare.gov
All data in this report comes from the CMS Care Compare database. You can review the official public record directly on Medicare.gov — including the full inspection narrative, star ratings, and any recent enforcement actions.
View on Medicare.gov ↗

This report reflects publicly available CMS data only and is updated monthly. Severity codes and narratives are reproduced directly from the CMS health inspection database. Senior Care Report Card scores are independently computed and are not affiliated with or endorsed by CMS or Medicare.gov.

Frequently asked questions

What is the Senior Care Report Card safety score for Bayshore Nursing & Rehab?
Bayshore Nursing & Rehab has an independently computed Safety Score of 45 out of 100, based on CMS inspection findings, staffing levels, penalty history, complaint volume, and quality measures.
Where is Bayshore Nursing & Rehab located?
Bayshore Nursing & Rehab is located in Glendale, WI. View the full address, phone number, and a map at the top of this report.
How many beds does Bayshore Nursing & Rehab have?
Bayshore Nursing & Rehab is certified for 112 beds in the CMS Care Compare dataset.
When was the most recent CMS health inspection at Bayshore Nursing & Rehab?
The most recent CMS health inspection summarized in this report was completed on September 30, 2025. CMS publishes a new inspection cycle approximately every 12 months.
What does the Senior Care Report Card Safety Score measure?
The Safety Score (0-100) combines five public-data signals: CMS health inspection severity, nursing staffing hours per resident, civil monetary penalties, complaint counts, and quality measures. Methodology and weightings are documented at /how-it-works/.
Is the report on Bayshore Nursing & Rehab affiliated with the facility?
No. This report is independently computed from public CMS Care Compare data and is not affiliated with Bayshore Nursing & Rehab, CMS, or Medicare.gov. It is provided as a research aid for families.

Data source: CMS Care Compare · Methodology · State Ombudsman

This report uses public CMS nursing home data and simplified scoring to help families ask better questions. It is not a recommendation, ranking, medical opinion, legal opinion, or substitute for an in-person visit. Source data last published by CMS: May 27, 2026.