Facility WatchInspection records for every certified US nursing home
Bayshore Nursing & Rehab
1300 West Silver Spring DR Glendale, WI 53209 (414) 228-8120
Special Focus Facility — SFF CandidateAbuse icon
CCN
525371
Certified beds
112
Ownership
For profit - Limited Liability company
Chain
Bedrock Healthcare
Nurse staffing
4.48
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.57 hours per resident per day
Nursing staff turnover: 61% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 30, 2026
4 citations · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected May 22, 2026
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected May 22, 2026
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected May 22, 2026
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 22, 2026
Inspected September 30, 2025
39 citations · from a complaint investigation · Health
C
F0577No actual harm with potential for minimal harm · Widespread
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0576No actual harm with potential for more than minimal harm · Isolated
Ensure residents have reasonable access to and privacy in their use of communication methods.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0605No actual harm with potential for more than minimal harm · Isolated
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0645No actual harm with potential for more than minimal harm · Isolated
PASARR screening for Mental disorders or Intellectual Disabilities
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0699No actual harm with potential for more than minimal harm · Isolated
Provide care or services that was trauma informed and/or culturally competent.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0700No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0790No actual harm with potential for more than minimal harm · Isolated
Provide routine and 24-hour emergency dental care for each resident.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected November 12, 2025
D
F0947No actual harm with potential for more than minimal harm · Isolated
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0582No actual harm with potential for more than minimal harm · Pattern
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0585No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0641No actual harm with potential for more than minimal harm · Pattern
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0679No actual harm with potential for more than minimal harm · Pattern
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0756No actual harm with potential for more than minimal harm · Pattern
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected November 12, 2025
E
F0883No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0727No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0851No actual harm with potential for more than minimal harm · Widespread
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0881No actual harm with potential for more than minimal harm · Widespread
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0887No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0925No actual harm with potential for more than minimal harm · Widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0946No actual harm with potential for more than minimal harm · Widespread
Provide training in compliance and ethics.
Deficient, Provider has date of correction · corrected November 12, 2025
F
F0949No actual harm with potential for more than minimal harm · Widespread
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Deficient, Provider has date of correction · corrected November 12, 2025
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 12, 2025
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected November 12, 2025
J
F0686Immediate jeopardy to resident health or safety · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected November 12, 2025
L
F0835Immediate jeopardy to resident health or safety · Widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected November 12, 2025
L
F0841Immediate jeopardy to resident health or safety · Widespread
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Deficient, Provider has date of correction · corrected November 12, 2025
Inspected July 30, 2025
1 citation · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected August 26, 2025
Inspected July 28, 2025
4 citations · from a complaint investigation · Health
C
F0732No actual harm with potential for minimal harm · Widespread
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected August 26, 2025
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 26, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 26, 2025
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 14, 2025
Inspected July 3, 2025
15 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 25, 2025
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 25, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected September 29, 2025
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected August 25, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0801No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0940No actual harm with potential for more than minimal harm · Widespread
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0941No actual harm with potential for more than minimal harm · Widespread
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0942No actual harm with potential for more than minimal harm · Widespread
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0943No actual harm with potential for more than minimal harm · Widespread
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0944No actual harm with potential for more than minimal harm · Widespread
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0945No actual harm with potential for more than minimal harm · Widespread
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0946No actual harm with potential for more than minimal harm · Widespread
Provide training in compliance and ethics.
Deficient, Provider has date of correction · corrected August 25, 2025
F
F0947No actual harm with potential for more than minimal harm · Widespread
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected August 25, 2025
J
F0692Immediate jeopardy to resident health or safety · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected November 14, 2025
Inspected May 29, 2025
9 citations · from a complaint investigation · Health
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected June 27, 2025
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected June 27, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected June 27, 2025
Inspected January 29, 2025
6 citations · from a complaint investigation · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 27, 2025
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected February 27, 2025
F
F0584No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected February 27, 2025
Inspected October 30, 2024
4 citations · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected December 2, 2024
F
F0584No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected February 27, 2025
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected December 2, 2024
F
F0925No actual harm with potential for more than minimal harm · Widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected December 2, 2024
Inspected July 24, 2024
1 citation · from a complaint investigation · Health
F
F0837No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected August 15, 2024
Inspected June 20, 2024
12 citations · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected July 25, 2024
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected July 25, 2024
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected July 25, 2024
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected July 25, 2024
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 25, 2024
F
F0908No actual harm with potential for more than minimal harm · Widespread
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected July 25, 2024
Inspected May 30, 2024
3 citations · from a complaint investigation · Health
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected June 16, 2024
E
F0655No actual harm with potential for more than minimal harm · Pattern
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected June 16, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected June 16, 2024
Inspected October 10, 2023
8 citations · from a complaint investigation · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 7, 2023
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 7, 2023
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected November 7, 2023
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 7, 2023
D
F0805No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Deficient, Provider has date of correction · corrected November 7, 2023
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected November 7, 2023
F
F0801No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 7, 2023
F
F0925No actual harm with potential for more than minimal harm · Widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected November 7, 2023
Inspected July 24, 2023
12 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0745No actual harm with potential for more than minimal harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0610No actual harm with potential for more than minimal harm · Pattern
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 22, 2023
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected August 22, 2023
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 22, 2023
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 22, 2023
G
F0744Actual harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected August 22, 2023
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 22, 2023
Inspected March 21, 2023
22 citations · Health
C
F0814No actual harm with potential for minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected June 13, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected June 13, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 17, 2023
D
F0804No actual harm with potential for more than minimal harm · Isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected May 17, 2023
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected May 17, 2023
E
F0623No actual harm with potential for more than minimal harm · Pattern
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected May 17, 2023
E
F0625No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected May 17, 2023
E
F0800No actual harm with potential for more than minimal harm · Pattern
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Deficient, Provider has date of correction · corrected May 17, 2023
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected May 17, 2023
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected July 24, 2023
G
F0760Actual harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected June 13, 2023
L
F0882Immediate jeopardy to resident health or safety · Widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected May 17, 2023
Penalties
Date
Type
Amount
October 30, 2024
Payment Denial · 36 days
Ownership transfers
Effective
Seller
Buyer
10/01/2019
Dycora Transitional Health-glendale LLC
Bedrock HCS at Glendale LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.