Cycle 1
Health 2025-09-30 · Fire 2025-09-30
68 health deficiencies
Top issue: Quality of Life and Care (15 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Glendale, WI
Bayshore Nursing & Rehab
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $178,395 in total fines with 68 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
1300 West Silver Spring Dr, Glendale, WI
(414) 228-8120
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
1984-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.08
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
1.6
2.1 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.1% |
95.7%
27.6 pts worse
|
93.4%
25.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 73.0% |
95.0%
22 pts worse
|
95.5%
22.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.2%
1.8 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
5.0%
4.7 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.8% |
4.9%
1.9 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
16.6%
1.8 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
16.7%
8.6 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.7% |
21.1%
13.4 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
17.3%
1.9 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
2.3%
1.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
3.0%
1.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
25.5%
3.7 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.5%
2 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.3% |
86.8%
62.5 pts worse
|
81.7%
57.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 17.9% |
82.2%
64.3 pts worse
|
79.7%
61.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
26 health deficiencies
Top issue: Resident Rights (9 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2023-03-21 · Fire 2023-03-21
49 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
15 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2026-01-05
F · Potential for more than minimal harm
2025-09-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-09-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-09-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-09-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-09-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-09-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-04-30
D · Potential for more than minimal harm
2025-09-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-09-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-09-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-09-30
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-09-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-09-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-15
F · Potential for more than minimal harm
2024-06-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-06-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-06-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-06-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-06-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-06-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-20
K233 · Egress Deficiencies
Fire Safety
Install resident room doors of proper design and width.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-20
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-06-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-06-20
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-06-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-06-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-25
F · Potential for more than minimal harm
2023-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-21
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-04-19
F · Potential for more than minimal harm
2023-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-04-19
Inspection history
Recent health citations
L · Immediate jeopardy
2025-09-30
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-11-12
L · Immediate jeopardy
2025-09-30
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2025-11-12
J · Immediate jeopardy
2025-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-12
J · Immediate jeopardy
2025-09-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-12
G · Actual harm
2025-09-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-11-12
F · Potential for more than minimal harm
2025-09-30
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-11-12
E · Potential for more than minimal harm
2025-09-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-09-30
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-11-12
C · Minimal harm
2025-09-30
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-11-12
D · Potential for more than minimal harm
2025-07-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-26
J · Immediate jeopardy
2025-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-14
D · Potential for more than minimal harm
2025-07-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-07-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-26
C · Minimal harm
2025-07-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-08-26
J · Immediate jeopardy
2025-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-11-14
F · Potential for more than minimal harm
2025-07-03
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-03
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-07-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-01-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-10-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-10-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-07-24
F837 · Administration Deficiencies
Health
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.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-25
F · Potential for more than minimal harm
2024-06-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-20
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-05-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-16
E · Potential for more than minimal harm
2024-05-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-16
E · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-16
F · Potential for more than minimal harm
2023-10-10
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-07
F · Potential for more than minimal harm
2023-10-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-10
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-11-07
J · Immediate jeopardy
2023-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
G · Actual harm
2023-07-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-22
G · Actual harm
2023-07-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
G · Actual harm
2023-07-24
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-08-22
F · Potential for more than minimal harm
2023-07-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-24
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-22
G · Actual harm
2023-05-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-05-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-05-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-22
L · Immediate jeopardy
2023-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-17
L · Immediate jeopardy
2023-03-21
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-05-17
G · Actual harm
2023-03-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-24
G · Actual harm
2023-03-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-03-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-03-21
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-03-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-03-21
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-03-21
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-05-17
E · Potential for more than minimal harm
2023-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-03-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-03-21
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-03-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-17
C · Minimal harm
2023-03-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-17
Penalties and ownership
What sits behind the stars
$0
2024-10-30
Payment Denial
Payment Denial · denial start 2025-01-22 · 36 days
36 day denial
$178,395
2023-03-21
Fine
Fine · fine $178,395
Fine
$0
2023-03-21
Payment Denial
Payment Denial · denial start 2023-04-20 · 124 days
124 day denial
Ownership
Bedrock Hc Wi LLC
5% Or Greater Direct Ownership Interest · Organization
Chopp, Martin
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Pnina
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Lynn
5% Or Greater Indirect Ownership Interest · Individual
Prager, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Prager, Shulamit
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Rachel
5% Or Greater Indirect Ownership Interest · Individual
Chopp, Sarah
5% Or Greater Indirect Ownership Interest · Individual
Nichols, Kenneth
Operational/Managerial Control · Individual
Nichols, Kenneth
Corporate Officer · Individual
Nichols, Kenneth
Contracted Managing Employee · Individual
Opal Healthcare Nj LLC
Operational/Managerial Control · Organization
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