F

Bayshore Nursing & Rehab

1300 WEST SILVER SPRING DR, GLENDALE, WI 53209
Score: 12 / 100
⚠️ SFF Candidate

With a score of 12/100, Bayshore Nursing & Rehab ranks in the bottom tier of Wisconsin nursing facilities, earning an F grade. CMS data highlights significant concerns that prospective residents and families should thoroughly evaluate.

Staffing levels are a potential concern at Bayshore Nursing & Rehab, with 3.42 total nursing hours per resident per day — below the national average of 3.8 hours. Lower staffing can impact care quality and staff responsiveness.

Recent CMS inspections identified 143 deficiencies at Bayshore Nursing & Rehab, including 9 classified as serious — among the most concerning citation levels. The most notable finding involved: administer the facility in a manner that enables it to use its resources effectively and efficiently..

Score Breakdown

Overall CMS Rating 8 / 40 pts
1 ★ CMS rating
Health Inspections 5 / 25 pts
1 ★ inspection rating
Staffing 8 / 20 pts
2 ★ staffing rating
Quality Measures 6 / 15 pts
2 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.42 3.8 Below Average
Registered Nurses (RN) 0.34 0.7 Below Average
Licensed Practical Nurses (LPN) 0.82 0.7 Above Average
Certified Nursing Assistants (CNA) 2.25 2.4 Average
Weekend Total Nursing 3.08 3.8 Below Average
Weekend RN Hours 0.25 0.7 Below Average

🔍 Inspection & Deficiency History

143
Total Deficiencies
Sep 29, 2025
Most Recent Inspection
⚪ 3 Minor 🟠 131 Moderate 🔴 9 Serious
View recent deficiencies (5 shown)
  • Tag 0835 Severity L
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    Sep 29, 2025 · Administration Deficiencies
  • Tag 0841 Severity L
    Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the fa
    Sep 29, 2025 · Nursing and Physician Services Deficiencies
  • Tag 0684 Severity J
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    Sep 29, 2025 · Quality of Life and Care Deficiencies
  • Tag 0686 Severity J
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Sep 29, 2025 · Quality of Life and Care Deficiencies
  • Tag 0689 Severity G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Sep 29, 2025 · Quality of Life and Care Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 7.5% 4.5% Worse
Falls with major injury 5.0% 3.0% Worse
On antipsychotic medication 25.3% 14.5% Worse
Urinary tract infections 1.2% 2.5% Better
ADL decline (daily activities) 15.4% 14.0% Worse
Excessive weight loss 6.8% 7.5% Average
New/worsened incontinence 21.8% 45.0% Better

⚠️ Penalties & Fines

1 penalty recorded by CMS

Total fines: $178,395

How This Grade Was Calculated

This facility's grade of F is based on a score of 12 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 1★ → 8 pts (max 40)
  • Health Inspection Rating: 1★ → 5 pts (max 25)
  • Staffing Rating: 2★ → 8 pts (max 20)
  • Quality Measures Rating: 2★ → 6 pts (max 15)
  • Penalty deductions: -5 pts
  • Fine deductions: -10 pts

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
112
Provider Type
Medicare and Medicaid
Resident Council
No
Family Council
No
Sprinkler System
Yes
Last Inspection
Sep 29, 2025
Deficiencies (Cycle 1)
68