Starfile / Wisconsin

Bayshore Nursing & Rehab

1300 WEST SILVER SPRING DR, GLENDALE, WI 53209 · CCN 525371

SFF Candidate Abuse icon

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$178,395

Number of fines

1

Number of penalties

3

Payment denials

2

Chain

Chain

BEDROCK HEALTHCARE

Facilities in chain

9

Chain avg overall

1.30 / 5

Inspection citations (143)9 immediate jeopardy7 actual harm

1. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

2. DF0576Ensure residents have reasonable access to and privacy in their use of communication methods.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

3. CF0577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.2025-09-30 · Health · corrected 2025-11-12

   Potential for minimal harm

4. EF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

5. DF0584Honor 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.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

6. EF0585Honor 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.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

7. DF0605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

8. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

9. DF0610Respond appropriately to all alleged violations.2025-09-30 · Health · corrected 2025-11-12

   Potential for more than minimal harm

10. DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

11. EF0641Ensure each resident receives an accurate assessment.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

12. DF0645PASARR screening for Mental disorders or Intellectual Disabilities2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

13. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

14. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

15. EF0679Provide activities to meet all resident's needs.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

16. JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-09-30 · Health · corrected 2025-11-12

    Immediate jeopardy

17. JF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-09-30 · Health · corrected 2025-11-12

    Immediate jeopardy

18. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-09-30 · Health · corrected 2025-11-12

    Actual harm

19. DF0699Provide care or services that was trauma informed and/or culturally competent.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

20. DF0700Try 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.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

21. FF0727Have 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.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

22. EF0730Observe each nurse aide's job performance and give regular training.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

23. EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

24. EF0761Ensure 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.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

25. DF0790Provide routine and 24-hour emergency dental care for each resident.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

26. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

27. LF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2025-09-30 · Health · corrected 2025-11-12

    Immediate jeopardy

28. LF0841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.2025-09-30 · Health · corrected 2025-11-12

    Immediate jeopardy

29. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

30. FF0851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

31. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

32. FF0880Provide and implement an infection prevention and control program.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

33. FF0881Implement a program that monitors antibiotic use.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

34. EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

35. FF0887Educate 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.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

36. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

37. FF0946Provide training in compliance and ethics.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

38. DF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

39. FF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-09-30 · Health · corrected 2025-11-12

    Potential for more than minimal harm

40. DF0558Reasonably accommodate the needs and preferences of each resident.2025-07-30 · Health · corrected 2025-08-26

    Potential for more than minimal harm

41. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-07-28 · Health · corrected 2025-08-26

    Potential for more than minimal harm

42. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-07-28 · Health · corrected 2025-08-26

    Potential for more than minimal harm

43. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-28 · Health · corrected 2025-11-14

    Immediate jeopardy

44. CF0732Post nurse staffing information every day.2025-07-28 · Health · corrected 2025-08-26

    Potential for minimal harm

45. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

46. DF0610Respond appropriately to all alleged violations.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

47. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-07-03 · Health · corrected 2025-09-29

    Potential for more than minimal harm

48. JF0692Provide enough food/fluids to maintain a resident's health.2025-07-03 · Health · corrected 2025-11-14

    Immediate jeopardy

49. DF0697Provide safe, appropriate pain management for a resident who requires such services.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

50. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

51. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

52. FF0940Develop, implement, and/or maintain an effective training program for all new and existing staff members.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

53. FF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

54. FF0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

55. FF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

56. FF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

57. FF0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

58. FF0946Provide training in compliance and ethics.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

59. FF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2025-07-03 · Health · corrected 2025-08-25

    Potential for more than minimal harm

60. DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

61. DF0584Honor 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.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

62. DF0641Ensure each resident receives an accurate assessment.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

63. DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

64. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

65. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

66. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

67. DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

68. EF0880Provide and implement an infection prevention and control program.2025-05-29 · Health · corrected 2025-06-27

    Potential for more than minimal harm

69. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

70. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

71. FF0584Honor 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.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

72. DF0585Honor 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.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

73. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

74. DF0759Ensure medication error rates are not 5 percent or greater.2025-01-29 · Health · corrected 2025-02-27

    Potential for more than minimal harm

75. FF0584Honor 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.2024-10-30 · Health · corrected 2025-02-27

    Potential for more than minimal harm

76. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-10-30 · Health · corrected 2024-12-02

    Potential for more than minimal harm

77. FF0814Dispose of garbage and refuse properly.2024-10-30 · Health · corrected 2024-12-02

    Potential for more than minimal harm

78. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-10-30 · Health · corrected 2024-12-02

    Potential for more than minimal harm

79. FF0837Establish 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.2024-07-24 · Health · corrected 2024-08-15

    Potential for more than minimal harm

80. DF0558Reasonably accommodate the needs and preferences of each resident.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

81. DF0578Honor 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.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

82. EF0584Honor 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.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

83. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

84. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

85. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

86. DF0692Provide enough food/fluids to maintain a resident's health.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

87. DF0761Ensure 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.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

88. FF0814Dispose of garbage and refuse properly.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

89. FF0880Provide and implement an infection prevention and control program.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

90. FF0908Keep all essential equipment working safely.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

91. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-06-20 · Health · corrected 2024-07-25

    Potential for more than minimal harm

92. EF0584Honor 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.2024-05-30 · Health · corrected 2024-06-16

    Potential for more than minimal harm

93. EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2024-05-30 · Health · corrected 2024-06-16

    Potential for more than minimal harm

94. EF0880Provide and implement an infection prevention and control program.2024-05-30 · Health · corrected 2024-06-16

    Potential for more than minimal harm

95. DF0584Honor 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.2023-10-10 · Health · corrected 2023-11-07

    Potential for more than minimal harm

96. DF0585Honor 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.2023-10-10 · Health · corrected 2023-11-07

    Potential for more than minimal harm

97. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-10-10 · Health · corrected 2023-11-07

    Potential for more than minimal harm

98. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-10 · Health · corrected 2023-11-07

    Potential for more than minimal harm

99. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2023-10-10 · Health · corrected 2023-11-07

    Potential for more than minimal harm

100. DF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2023-10-10 · Health · corrected 2023-11-07

     Potential for more than minimal harm

101. DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2023-10-10 · Health · corrected 2023-11-07

     Potential for more than minimal harm

102. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2023-10-10 · Health · corrected 2023-11-07

     Potential for more than minimal harm

103. GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-07-24 · Health · corrected 2023-08-22

     Actual harm

104. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

105. EF0610Respond appropriately to all alleged violations.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

106. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

107. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

108. DF0679Provide activities to meet all resident's needs.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

109. JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-07-24 · Health · corrected 2023-08-22

     Immediate jeopardy

110. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-07-24 · Health · corrected 2023-08-22

     Actual harm

111. GF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2023-07-24 · Health · corrected 2023-08-22

     Actual harm

112. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

113. DF0758Implement 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.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

114. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2023-07-24 · Health · corrected 2023-08-22

     Potential for more than minimal harm

115. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-05-17 · Health · corrected 2023-08-22

     Potential for more than minimal harm

116. DF0610Respond appropriately to all alleged violations.2023-05-17 · Health · corrected 2023-08-22

     Potential for more than minimal harm

117. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-05-17 · Health · corrected 2023-08-22

     Actual harm

118. EF0584Honor 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.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

119. EF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

120. EF0625Notify 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.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

121. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

122. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

123. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

124. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

125. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-03-21 · Health · corrected 2023-07-24

     Actual harm

126. DF0691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

127. DF0692Provide enough food/fluids to maintain a resident's health.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

128. DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

129. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2023-03-21 · Health · corrected 2023-06-13

     Potential for more than minimal harm

130. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

131. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

132. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2023-03-21 · Health · corrected 2023-06-13

     Potential for more than minimal harm

133. DF0758Implement 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.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

134. DF0759Ensure medication error rates are not 5 percent or greater.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

135. GF0760Ensure that residents are free from significant medication errors.2023-03-21 · Health · corrected 2023-06-13

     Actual harm

136. DF0761Ensure 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.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

137. EF0800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

138. DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

139. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-03-21 · Health · corrected 2023-05-17

     Potential for more than minimal harm

140. CF0814Dispose of garbage and refuse properly.2023-03-21 · Health · corrected 2023-05-17

     Potential for minimal harm

141. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2023-03-21 · Health · corrected 2023-08-22

     Potential for more than minimal harm

142. LF0880Provide and implement an infection prevention and control program.2023-03-21 · Health · corrected 2023-05-17

     Immediate jeopardy

143. LF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2023-03-21 · Health · corrected 2023-05-17

     Immediate jeopardy

Ownership

Other facilities in GLENDALE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.