Bayshore Residence and Rehabilitation Center
1601 St Louis Avenue, Duluth, MN 55802 · St. Louis County · 140 certified beds · avg 98 residents/day · certified since Jan 22, 1979
Part of chain: EPHRAM LAHASKY (22 facilities, chain avg rating 1.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jun 27, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 6, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 28, 2024 · F-0578
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 21, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 20, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 16, 2024 (Past Non-Compliance)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 26, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 26, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Jun 26, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 26, 2026 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jun 26, 2026 | B · Minimal risk, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Apr 17, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Apr 17, 2025 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jun 27, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 28, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| May 28, 2024 | E · Potential for harm, repeated | The facility did not verify that its nurse aides had completed their required training, or did not retrain aides who had been out of nurse aide work for 2 years. |
| May 28, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 28, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 28, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 20, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 12 | 3 | K ▲ |
| 2025 | 15 | 0 | E |
| 2026 | 10 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $132,398, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 28, 2024 | Fine | $122,175 |
| May 28, 2024 | Payment Denial | 10 days from Jun 26, 2024 |
| Apr 20, 2024 | Fine | $10,223 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.46 | 4.83 | 3.95 | bottom 35% in Minnesota; top 24% in the U.S. |
| Registered Nurse hours | 1.04 | 1.22 | 0.69 | bottom 41% in Minnesota; top 14% in the U.S. |
| Weekend total nurse staffing | 3.91 | 4.27 | 3.50 | bottom 35% in Minnesota; top 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.54 | 0.69 | 0.48 | bottom 42% in Minnesota; top 29% in the U.S. |
| Total nursing staff turnover (%) | 58.0 | 42.2 | 45.8 | bottom 13% in Minnesota; bottom 20% in the U.S. |
| RN turnover (%) | 30.0 | 38.6 | 42.9 | top 40% in Minnesota; top 29% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.56, RN 0.83, weekend 3.12. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cbay Bayshore Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 13% | 03/31/2016 |
| Katz, Abe | Individual | 5% or Greater Direct Ownership Interest | 21% | 03/31/2016 |
| MB Duluth Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 21% | 03/31/2016 |
| Babbitt, Don | Individual | W-2 Managing Employee | NOT APPLICABLE | 03/31/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you explain health changes and treatment options to residents and their families?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Franciscan Health Center | 2.1 mi | Duluth, MN | ★☆☆☆☆ | 2/5 | |
| Benedictine Health Center | 3.2 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | abuse |
| Aftenro Home | 3.3 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | |
| Viewcrest Health Center | 3.6 mi | Duluth, MN | ★★★☆☆ | 3/5 | |
| Hilltop Healthcare Rehabilitation and Skilled Nurs | 4.0 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Dove Healthcare - Superior | 4.1 mi | Superior, WI | ★★☆☆☆ | 2/5 | |
| Villa Marina Health and Rehabilitation Center | 4.3 mi | Superior, WI | ★★★★☆ | 3/5 | |
| Ecumen Lakeshore | 4.3 mi | Duluth, MN | ★★★★★ | 5/5 | |
| Twin Ports Health Services | 5.1 mi | Superior, WI | ★★★★★ | 4/5 | |
| The North Shore Estates LLC | 5.9 mi | Duluth, MN | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245227.