Map showing the location of Bayshore Nursing & Rehab in GLENDALE, Wisconsin
1300 WEST SILVER SPRING DR, GLENDALE, WI, 53209

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • WisconsinLowest tier among peers321 rated homes · average 3.0★
  • Milwaukee CountyLowest tier among peers32 rated homes · average 2.4★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs WI avg
  • StaffingCan add or remove a star2★−1.7 vs WI avg
  • Quality measuresCan add or remove a star2★−1.1 vs WI avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersWI avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 7% of peersWI avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 8% of peersWI avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.42hrsAbove only 14% of peersWI avg4.19Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.34hrsAbove only 1% of peersWI avg0.96Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better60%Above only 21% of peersWI avg48%RN turnover67%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$178,395Above only 7% of peersWI avg$41,875Fines · denials1 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
143citations
14inspection dates
7actual harm (G–I)
9immediate jeopardy (J–L)
Sep 30, 2025most recent

Citations by monthMar 2023 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 30, 202539 citationsCycle 1worst L · immediate jeopardy
  1. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Nov 12, 2025
  2. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Nov 12, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareJ · isolatedCorrected Nov 12, 2025
  4. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Nov 12, 2025
  5. F700Try 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.Quality of Life and CareD · isolatedCorrected Nov 12, 2025
  6. F727Have 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.Nursing and Physician ServicesF · widespreadCorrected Nov 12, 2025
  7. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Nov 12, 2025
  8. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Nov 12, 2025
  9. F761Ensure 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.Pharmacy ServiceE · patternCorrected Nov 12, 2025
  10. F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected Nov 12, 2025
  11. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 12, 2025
  12. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationL · widespreadCorrected Nov 12, 2025
  13. F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Nursing and Physician ServicesL · widespreadCorrected Nov 12, 2025
  14. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Nov 12, 2025
  15. F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Nov 12, 2025
  16. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Nov 12, 2025
  17. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Nov 12, 2025
  18. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 12, 2025
  19. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 12, 2025
  20. F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationF · widespreadCorrected Nov 12, 2025
  21. F585Honor 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.Resident RightsE · patternCorrected Nov 12, 2025
  22. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 12, 2025
  23. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Nov 12, 2025
  24. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Nov 12, 2025
  25. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 12, 2025
  26. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 12, 2025
  27. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Nov 12, 2025
  28. F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Nov 12, 2025
  29. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Nov 12, 2025
  30. F887Educate 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.Infection ControlF · widespreadCorrected Nov 12, 2025
  31. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Nov 12, 2025
  32. F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Nov 12, 2025
  33. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 12, 2025
  34. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Nov 12, 2025
  35. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Nov 12, 2025
  36. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Nov 12, 2025
  37. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsC · widespreadCorrected Nov 12, 2025
  38. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsE · patternCorrected Nov 12, 2025
  39. F584Honor 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.Resident RightsD · isolatedCorrected Nov 12, 2025
Jul 30, 20251 citationCycle 1worst D · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Aug 26, 2025
Jul 28, 20254 citationsCycle 1worst J · immediate jeopardy
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 26, 2025
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 26, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Nov 14, 2025
  4. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Aug 26, 2025
Jul 3, 202515 citationsCycle 1worst J · immediate jeopardy
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 25, 2025
  2. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationF · widespreadCorrected Aug 25, 2025
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 25, 2025
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 25, 2025
  5. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareJ · isolatedCorrected Nov 14, 2025
  6. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Aug 25, 2025
  7. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 29, 2025
  8. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Aug 25, 2025
  9. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationF · widespreadCorrected Aug 25, 2025
  10. F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationF · widespreadCorrected Aug 25, 2025
  11. F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Resident RightsF · widespreadCorrected Aug 25, 2025
  12. F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Aug 25, 2025
  13. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlF · widespreadCorrected Aug 25, 2025
  14. F946Provide training in compliance and ethics.AdministrationF · widespreadCorrected Aug 25, 2025
  15. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Aug 25, 2025
May 29, 20259 citationsCycle 1worst E · no actual harm
  1. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jun 27, 2025
  2. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jun 27, 2025
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 27, 2025
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 27, 2025
  5. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jun 27, 2025
  6. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 27, 2025
  7. F584Honor 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.Resident RightsD · isolatedCorrected Jun 27, 2025
  8. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 27, 2025
  9. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 27, 2025
Jan 29, 20256 citationsCycle 2worst F · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 27, 2025
  2. F585Honor 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.Resident RightsD · isolatedCorrected Feb 27, 2025
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 27, 2025
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Feb 27, 2025
  5. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Feb 27, 2025
  6. F584Honor 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.Resident RightsF · widespreadCorrected Feb 27, 2025
Oct 30, 20244 citationsCycle 2worst F · no actual harmpayment denial
  1. F584Honor 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.Resident RightsF · widespreadCorrected Feb 27, 2025
  2. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Dec 2, 2024
  3. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Dec 2, 2024
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 2, 2024
Jul 24, 20241 citationCycle 2worst F · no actual harm
  1. F837Establish 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.AdministrationF · widespreadCorrected Aug 15, 2024
Jun 20, 202412 citationsCycle 2worst F · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 25, 2024
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 25, 2024
  3. F578Honor 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.Resident RightsD · isolatedCorrected Jul 25, 2024
  4. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 25, 2024
  5. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 25, 2024
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Jul 25, 2024
  7. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jul 25, 2024
  8. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Jul 25, 2024
  9. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 25, 2024
  10. F908Keep all essential equipment working safely.EnvironmentalF · widespreadCorrected Jul 25, 2024
  11. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Jul 25, 2024
  12. F584Honor 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.Resident RightsE · patternCorrected Jul 25, 2024
May 30, 20243 citationsCycle 2worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Jun 16, 2024
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 16, 2024
  3. F584Honor 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.Resident RightsE · patternCorrected Jun 16, 2024
Oct 10, 20238 citationsCycle 3worst F · no actual harm
  1. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Nov 7, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 7, 2023
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 7, 2023
  4. F584Honor 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.Resident RightsD · isolatedCorrected Nov 7, 2023
  5. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Nov 7, 2023
  6. F585Honor 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.Resident RightsD · isolatedCorrected Nov 7, 2023
  7. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Nov 7, 2023
  8. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Nov 7, 2023
Jul 24, 202312 citationsCycle 3worst J · immediate jeopardy
  1. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareG · isolatedCorrected Aug 22, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Aug 22, 2023
  3. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Aug 22, 2023
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 22, 2023
  5. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Aug 22, 2023
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Aug 22, 2023
  7. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Aug 22, 2023
  8. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Aug 22, 2023
  9. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 22, 2023
  10. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Aug 22, 2023
  11. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 22, 2023
  12. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Aug 22, 2023
May 17, 20233 citationsCycle 3worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 22, 2023
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 22, 2023
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 22, 2023
Mar 21, 202326 citationsCycle 3worst L · immediate jeopardy$178,395, payment denial
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected May 17, 2023
  2. F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 17, 2023
  3. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Aug 22, 2023
  4. F880Provide and implement an infection prevention and control program.Infection ControlL · widespreadCorrected May 17, 2023
  5. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected May 17, 2023
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 17, 2023
  7. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 13, 2023
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 17, 2023
  9. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected May 17, 2023
  10. F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 17, 2023
  11. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected May 17, 2023
  12. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceG · isolatedCorrected Jun 13, 2023
  13. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 17, 2023
  14. 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.Resident RightsE · patternCorrected May 17, 2023
  15. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jun 13, 2023
  16. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 17, 2023
  17. F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and DietaryE · patternCorrected May 17, 2023
  18. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected May 17, 2023
  19. F814Dispose of garbage and refuse properly.Nutrition and DietaryC · widespreadCorrected May 17, 2023
  20. F584Honor 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.Resident RightsE · patternCorrected May 17, 2023
  21. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 17, 2023
  22. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jul 24, 2023
  23. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 17, 2023
  24. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected May 17, 2023
  25. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected May 17, 2023
  26. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlL · widespreadCorrected May 17, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.42hrsAbove only 14% of peers−0.77 vs WI avg
  • Registered nursesRN hours only0.34hrsAbove only 1% of peers−0.62 vs WI avg
  • Licensed practical nursesLPN hours0.82hrs
  • Nurse aidesCNA hours2.25hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.08hrs
  • Wisconsin average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better60%Above only 21% of peersWI avg 48%
  • RN turnoverRegistered nurses only67%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy112 certified beds · ~89 residents a day80%Above 61% of peersWI avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $178,395In fines
  • 1Fine
  • 2Payment denials
  • $41,875WI avg in fines
Above only 7% of peersFewer fines than 7% of rated homes in Wisconsin

Actions on record

  1. Oct 30, 2024Denial of payment for new admissionsfrom Jan 22, 2025
  2. Mar 21, 2023Civil money penalty$178,395
  3. Mar 21, 2023Denial of payment for new admissionsfrom Apr 20, 2023

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Bedrock Healthcare8 facilities in the chain1.1★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Bedrock Hc Wi LLC
Indirect owners (5%+)
  • Lynn Chopp
  • Martin Chopp
  • Pnina Chopp
  • Rachel Chopp
  • Sarah Chopp
  • Solomon Chopp
  • Avrohom Prager
  • Shulamit Prager
Operational or managerial control
  • Opal Healthcare Nj LLC
  • Kenneth Nichols
Corporate officers
  • Kenneth Nichols
Contracted managers
  • Kenneth Nichols

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 525371 · 1300 WEST SILVER SPRING DR, GLENDALE, WI, 53209.
  • Percentiles compare this facility with every rated nursing home in Wisconsin and Milwaukee County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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