Bayshore Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Bayshore Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Sep 30, 2025

  Based on observation, interview, and record review, the facility was not administered in a manner that enabled it to use its resources effectively to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to affect all 85 residents residing in the facility at the time of the survey.*The facility did not provide skin care treatments based upon accepted standards of practice and assessments. Residents sustained avoidable deterioration in wounds as a result of not being thoroughly assessed, care planned for interventions to prevent decline, and ongoing monitoring with revisions to the care plan. Wounds became infected and necrotic. Hospitalizations were required. […]

• Immediate jeopardy, widespreadF841Sep 30, 2025

  Based on interview and record review, the facility did not ensure the medical director followed through on his responsibilities regarding the coordination of care and treatment the residents received in the facility. This has the likelihood to cause serious harm, injury, or impairment to all 85 residents currently residing in the facility.Medical Director (MD)-QQ was not aware of and did not ensure facility residents with wounds had care and treatment necessary to prevent and heal pressure and non-pressure injury wounds. Medical Director-QQ deferred all wound care and treatment to the facility's wound team and Wound MD (Medical Doctor). […]

• Immediate jeopardy, widespreadF880Mar 21, 2023

  Based on observations, interviews and record review, the facility did not implement an effective infection control and prevention program during a COVID-19 outbreak in the facility. This deficient practice has the potential to affect all 100 residents in the facility. As of 3/16/23, the facility was having a COVID-19 outbreak with 5 staff members and 24 out of 100 residents had tested positive for COVID-19. The outbreak began on 2/9/23 when one resident (R77) tested positive while at the hospital. R77 was sent to the hospital on 2/9/23, where they were tested for COVID-19 and were positive. The facility was not aware of R77 testing positive for COVID-19 until 2/14/23. On 2/14/23, the facility began testing all staff and residents for COVID-19 and no other staff or resident tested positive. […]

• Immediate jeopardy, widespreadF882Mar 21, 2023

  Based on observation, interview, and record review, the facility did not ensure the designated Infection Preventionist (IP), Assistant Director of Nursing C was qualified as an IP to assess, develop, monitor, and manage the Infection Prevention and Control Program. This deficient practice has the potential to affect all 100 residents in the facility. * Director of Nursing (DON) B completed a certification in an infection control program in October of 2022. Corporate Consultant F informed Surveyor, DON B delegates the IP duties to Assistant Director of Nursing (ADON) C. Assistant Director of Nursing (ADON) C and Corporate Consultant F informed Surveyor ADON C is designated as the facility's IP. ADON C has not yet completed a certification in an infection control program. […]

• Immediate jeopardy, isolatedF684Sep 30, 2025

  Based on observation, interview, and record review, the facility did not ensure residents received treatment and care, based on a comprehensive assessment, in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for non-pressure injuries, changes of condition, neurological checks after unwitnessed falls, or physician follow up visits for 3 (R97, R98, and R73) of 20 sampled residents. R97 developed an infection in a surgical wound and developed other non-pressure wounds that were not comprehensively assessed by a Registered Nurse (RN) or treated despite physician orders. […]