Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bayshore Nursing & Rehab
GLENDALE, WI · 112 certified beds · Last Life Safety survey September 30, 2025
CMS Certification Number 525371 · first certified October 1984
Ownership
Operated by BEDROCK HEALTHCARE · For profit - Limited Liability company
- Ownership changed October 1, 2019 (change of ownership)to SILVER SPRINGS HEALTH CARE CENTER from DYCORA TRANSITIONAL HEALTH-GLENDALE LLC
Position within WI
51 citations — more than 100% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 20 citations; the earlier surveys in the window averaged 15.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was September 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 51 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
23 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 51 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 51 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 21, 2023 | 15 |
| June 20, 2024 | 16 |
| September 30, 2025 | 20 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-09-30 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-09-30 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-09-30 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-09-30 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-09-30 |
| K-0271 | Have exits that are accessible at all times. | 3 | 2025-09-30 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-09-30 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-09-30 |
What the citations cover
- Smoke Deficiencies 18
- Egress Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 8
- Miscellaneous Deficiencies 7
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Egress Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 8 |
| Miscellaneous Deficiencies | 7 |
| Services Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 30, 2025 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 15, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (January 5, 2026) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has plan of correction |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 30, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 15, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 15, 2025) |
June 20, 2024 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 18, 2024) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (July 25, 2024) |
| K-0233 | Install resident room doors of proper design and width. | Deficient, Provider has date of correction (July 25, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 25, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 19, 2024) |
March 21, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 19, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 19, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.