Bayshore Residence and Rehabilitation Center
1601 St Louis Avenue · Duluth, MN · 55802 · 2187278651
140 certified beds For profit - Limited Liability company Chain: Ephram Lahasky
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 5 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.80 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.88 | 0.55–0.75 |
| Weekend hours / resident-day | 3.28 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | 2 · $132,398 |
Inspection citations (37 in the current record)
-
Potential for harm · D December 4, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 16, 2025 · Resident Rights
-
Potential for harm · D December 4, 2025 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected December 16, 2025 · Resident Rights
-
Potential for harm · D April 17, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected May 20, 2025 · Resident Rights
-
Potential for harm · D April 17, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected May 20, 2025 · Resident Rights
-
Potential for harm · D April 17, 2025
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 May 20, 2025 · Resident Rights
-
Potential for harm · D April 17, 2025
Ensure each resident receives an accurate assessment.
Corrected May 20, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D April 17, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 20, 2025 · Quality of Life and Care
-
Potential for harm · D April 17, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 20, 2025 · Quality of Life and Care
-
Potential for harm · D April 17, 2025
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 May 20, 2025 · Quality of Life and Care
-
Potential for harm · D April 17, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 20, 2025 · Pharmacy Service
-
Potential for harm · D April 17, 2025
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 May 20, 2025 · Pharmacy Service
-
Potential for harm · E April 17, 2025
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 May 20, 2025 · Pharmacy Service
-
Potential for harm · D April 17, 2025
Provide and implement an infection prevention and control program.
Corrected May 20, 2025 · Infection Control
-
Potential for harm · D April 17, 2025
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected May 20, 2025 · Environmental
-
No harm found · C April 17, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected May 20, 2025 · Resident Rights
-
Immediate jeopardy · K June 27, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J May 28, 2024
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 June 21, 2024 · Resident Rights
-
Potential for harm · E May 28, 2024
Honor the resident's right to manage his or her financial affairs.
Corrected June 21, 2024 · Resident Rights
-
Potential for harm · D May 28, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected June 21, 2024 · Resident Rights
-
Potential for harm · D May 28, 2024
Ensure each resident receives an accurate assessment.
Corrected June 21, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D May 28, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected June 21, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D May 28, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 21, 2024 · Quality of Life and Care
-
Potential for harm · D May 28, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 21, 2024 · Quality of Life and Care
-
Potential for harm · E May 28, 2024
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected June 21, 2024 · Nursing and Physician Services
-
Potential for harm · E May 28, 2024
Provide and implement an infection prevention and control program.
Corrected June 21, 2024 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 28, 2024 | Fine | $122,175 |
| May 28, 2024 | Payment Denial | 10 days |
| April 20, 2024 | Fine | $10,223 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245227 · certified since January 22, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.