CareSentinel

Federal Nursing-Home Survey Record

BAYSHORE RESIDENCE AND REHABILITATION CENTER

CCN 245227 · 1601 ST LOUIS AVENUE, DULUTH, MN, 55802 · Operated within the EPHRAM LAHASKY chain

Does BAYSHORE RESIDENCE AND REHABILITATION CENTER have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), BAYSHORE RESIDENCE AND REHABILITATION CENTER (CCN 245227), in DULUTH, MN, has federal inspection findings on its record. In its current inspection cycle, CMS cited the facility for 15 deficiencies; the most serious carries scope/severity E. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $132,398 in civil money penalties on file against the facility. This page restates the federal record and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with federal regulators; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.

The Federal Record

CMS has $132,398 in civil money penalties on file against this facility.

Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations, as on file with federal regulators (CMS).

Civil money penalties on file

$132,398

CMS has $132,398 in civil money penalties on file against this facility. CMS also records 10 day(s) of payment denial.

Overall CMS star rating: this facility vs the CMS-published state average

This facility: 2  ·  CMS state average: 3.2

Side-by-side with the CMS-published Overall CMS star rating for this state. This is the government's own published state average — not a CareSentinel-computed figure or delta.

Deficiency timeline — full federal history

2025-12-04
CURRENT CYCLE
F550S/S D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

2025-12-04
CURRENT CYCLE
F627S/S D

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

2025-04-17
CURRENT CYCLE
F761S/S E

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.

2025-04-17
CURRENT CYCLE
F909S/S D

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.

2025-04-17
CURRENT CYCLE
F554S/S D

Allow residents to self-administer drugs if determined clinically appropriate.

2025-04-17
CURRENT CYCLE
F557S/S D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

2025-04-17
CURRENT CYCLE
F584S/S D

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.

2025-04-17
CURRENT CYCLE
F641S/S D

Ensure each resident receives an accurate assessment.

2025-04-17
CURRENT CYCLE
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2025-04-17
CURRENT CYCLE
F686S/S D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

2025-04-17
CURRENT CYCLE
F700S/S D

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.

2025-04-17
CURRENT CYCLE
F757S/S D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

2025-04-17
CURRENT CYCLE
F758S/S D

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.

2025-04-17
CURRENT CYCLE
F880S/S D

Provide and implement an infection prevention and control program.

2025-04-17
CURRENT CYCLE
F577S/S C

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

2024-06-27
HISTORICAL
F600S/S K

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

2024-05-28
HISTORICAL
F578S/S J

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.

2024-05-28
HISTORICAL
F567S/S E

Honor the resident's right to manage his or her financial affairs.

2024-05-28
HISTORICAL
F729S/S E

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

2024-05-28
HISTORICAL
F880S/S E

Provide and implement an infection prevention and control program.

2024-05-28
HISTORICAL
F689S/S D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2024-05-28
HISTORICAL
F580S/S D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

2024-05-28
HISTORICAL
F582S/S D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

2024-05-28
HISTORICAL
F641S/S D

Ensure each resident receives an accurate assessment.

2024-05-28
HISTORICAL
F684S/S D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2024-05-28
HISTORICAL
F658S/S D

Ensure services provided by the nursing facility meet professional standards of quality.

2024-04-20
HISTORICAL
F689S/S J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2023-07-25
HISTORICAL
F609S/S D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2023-06-23
HISTORICAL
F761S/S E

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.

2023-06-23
HISTORICAL
F812S/S E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2023-06-23
HISTORICAL
F880S/S E

Provide and implement an infection prevention and control program.

2023-06-23
HISTORICAL
F567S/S E

Honor the resident's right to manage his or her financial affairs.

2023-06-23
HISTORICAL
F698S/S D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

2023-06-23
HISTORICAL
F695S/S D

Provide safe and appropriate respiratory care for a resident when needed.

2023-06-23
HISTORICAL
F690S/S D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

2023-06-23
HISTORICAL
F689S/S D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2023-06-23
HISTORICAL
F657S/S D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Each citation below is a federal survey finding, dated and labeled with its CMS deficiency tag, as on file with federal regulators (CMS). Older inspection cycles are de-emphasized; only the most recent cycle is current.

Document what happened

Were you or a loved one harmed at BAYSHORE RESIDENCE AND REHABILITATION CENTER?

Share a few details to put your inquiry on file. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. As qualified attorneys join our network in your area, one may reach out — we can’t guarantee contact yet, so we encourage you to consult a qualified attorney promptly on your own as well. There is no cost, and your information is handled with care.

Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.

Step 1 of 3 · What happened

Your relationship to the resident
What happened? Select all that apply.

Physical injury

Skin & wounds

Medical & clinical

Safety & abuse

Loss

Something else

The resident is…