Bayshore Residence And Rehabilitation Center
1601 St Louis Avenue, Duluth, MN 55802 · For profit - Limited Liability company · 140 certified beds · (218) 727-8651 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $132,398 in federal fines (most recent 2024-05-28)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.3% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.9% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.8% | 2.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 5.0% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.7% | 4.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.2% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.3% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.0% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 92.3% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.4% | 23.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 24.6% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.77 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.66 | 1.90 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.2%CMS range 46.2–75.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.6–15.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 75.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 11.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 3.8–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 98.2 residents a day — about 70% occupied, or roughly 42 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.12 hrs/resident/day on weekends vs 3.74 on weekdays — 17% thinner on weekends. RN hours go from 0.95 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
37 citations, most serious first. The 13 most serious are shown; the remaining 24 are one tap away and print in full.
- Immediate jeopardy · K2024-06-27 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents were free from mental and emotional abuse for 4 of 4 residents (R1, R2, R3, R4) when nursing assistant (NA)-A took humiliating photographs of residents and video recordings of residents which NA-A then posted on Snapchat (social media). In addition, the facility failed to ensure residents were free from physical abuse when NA-A physically abused R1 when assisting R1 into bed. NA-A also video taped this abuse and posted on Snapchat. These actions had the potential to cause serious psychosocial and physical harm to residents. This deficient practice resulted in an immediate jeopardy (IJ). The IJ began on 6/17/24, when the Minnesota Department of Health received an allegation that NA-A shared numerous pictures and videos on social media of R1, R2, R3 and R4. The pictures contained exposed resident private areas, residents in underwear, lewd gestures from NA-A to residents, and videos of NA-A abusing a resident. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-05-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life Sustaining Treatment (POLST) and physician orders to ensure the residents wishes would be followed in the event of a cardiac arrest. This resulted in an immediate jeopardy for 1 of 34 residents (R86) who's code status was not accurately documented and was reviewed for advanced directives. The immediate jeopardy (IJ) began on [DATE], at R86's first care conference. The care conference identified R86 and family member (FM)-A as being in attendance. Section C Nursing included the following: Resident continues to be a full code. Section E Social Services identified R86's code status as Full Code. R86's POLST located in the EHR scanned documents dated [DATE], identified R86 as Do Not Resuscitate. In addition, when the facility became aware of the discrepancy they changed the banner in the EHR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2024-04-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when he eloped from the facility, was not identified as missing for 1.25 hours and found 2 miles away from the facility. The IJ began on 4/15/24 at 6:37 a.m. when nursing assistant (NA)-A saw R1 outside of the facility on the sidewalk in front of the building, mistook him for a visitor, and cleared the wanderguard door alarm without searching for a missing resident. The administrator and director of nursing (DON) were informed of the IJ on 4/18/24 at 4:30 p.m. The facility had implemented corrective action on 4/16/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's Face Sheet undated indicated R1 had diagnoses of bipolar disorder and metabolic encephalopathy. R1's Elopement Risk Evaluation dated 4/10/24, indicated R1 had a history of exit seeking and attempting to leave the building which put him at risk for elopement. R1's Brief Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-26 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to properly dispose of medications in the second-floor medication storage room. This had the ability to affect any resident who received medications from the second-floor medication storage room. Findings include: During a tour of the second-floor medication room with licensed practical nurse (LPN)-D on 6/25/26 at 9:23 a.m., multiple medications were observed to be expired. LPN-D stated that he wasn't sure of the process to remove the expired medications and I would have to follow up with director of nursing (DON). LPN-D stated that a lot of the medications in the medication storage room were overflow. Expired medications included the following: -saline nasal gel, expired 4/28/25-magnesium chloride, expired 4/9/26-docusate sodium, expired 12/4/25-cephalaxin, filled 9/16/25-Tylenol assigned to R19, expired 6/18/25. During an interview on 6/25/26 at 12:34 p.m., the director of nursing (DON) stated the nurse managers, or her audit medication carts monthly, but she had not audited the second-floor medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-26 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure meals were palatable for 8 of 14 residents (R17, R12, R10, R4, R5, R58, R61, R81) who expressed dissatisfaction with palatability of meals. In addition, the facility failed to ensure the temperature of foods was maintained when transported to resident rooms. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was moderately cognitively intact. During an interview on 6/22/26 at 2:30 p.m., R17 stated the food was pretty much terrible. During an observation on 6/24/26 at 1:02 p.m., R17 was no longer in the main dining room. He had eaten only a few bites of the meal which was a French dip sandwich, French fries, and a creamy cucumber salad. R12's quarterly MDS dated [DATE], identified R12 was cognitively intact. During an interview on 6/22/26 at 3:15 p.m., R12 stated the food was poor quality, said the cooks didn't know how to cook, and went on to state the hot food was not hot, and ice cream was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher. Additionally, the facility failed to ensure proper sanitary storage of cleaning products and personal protective equipment and failed to ensure staff appropriately covered facial hair.Findings include: Dishwasher temperatures:During an observation on 6/25/26 at 9:38 a.m., dietary aide (DA)-A was operating the dirty side of the dishwasher and DA-B was removing dishes on the clean side of the dishwasher. DA-A completed a wash cycle. On the dishwasher, the rinse temperature was observed to be 180 degrees Fahrenheit (F), and the wash temperature gauge was not functioning.During an interview on 6/25/26 at 10:11 a.m., DA-A stated dishwasher temperatures were logged by staff working…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure residents were informed of and consented to medications prescribed and given for mental health intervention for 1 of 5 residents (R2) reviewed for unnecessary medications.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact.R2's diagnoses included heart failure, renal insufficiency, schizoaffective disorder, non-Alzheimer's dementia, and arthritis.R2's care plan dated 6/26/26, identified R2 uses psychotropic medications related to behavior management. R2's provider orders dated 8/18/25, included mirtazapine oral tablet 15 mg: Give 15 mg by mouth at bedtime for depression. R2's provider orders dated 8/19/25, included risperidone oral tablet 0.5 mg: Give 1 tablet by mouth two times a day for mood disorder.R2's Informed Consent for Required Medications dated 2/5/24, for risperidone 2.5 mg two times a day for bipolar, was signed by R2.R2's medical record had no Informed Consent for Required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure that a resident who was assessed to be unable to self-administer medications did not self-administer nebulizer treatments. This affected 1 of 1 resident (R8) reviewed for self-administration of medication.Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 as cognitively intact. Diagnosis included chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA). R8's MDS further indicated that she was assessed as unable to self-administer medications. R8's current orders, reviewed 6/24/26, included Albuterol Sulfate Inhalation Nebulization Solution 2.5 milligrams (mg), inhale orally three times a day. Current orders failed to indicate R8 was able to self-administer medications. During observation on 6/24/26 at 11:00 a.m., R8's nebulizer sat atop her bedside table with noted droplets in the nebulizer chamber. During interview on 6/24/26 at 11:47 a.m., R8 stated that she uses her nebulizer three times…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facilty failed to honor shaving preferences and needed assistance for 1 of 1 residents (R112) who required minimal assistance with shaving and oral care. Findings include:R112's admission Minimum Data Set (MDS) dated [DATE], status: ready for export, indicated R112 was cognitively intact with the diagnoses of encounter for orthopedic after care, kidney disease, diabetes, congestive heart failure and muscle weakness. Section GG indicated R112 required setup or clean-up assistance for personal hygiene including shaving and oral hygiene. R112's care plan last updated dated 6/23/26, did not include R112's general preferences or activities of living (ADL) preferences. The Focus area Functional Discharge Goals included: hygiene goal: set up or clean up assistance with personal hygiene. The oral hygiene goal identified was to be independent with oral hygiene. On 6/22/26 at 2:04 p.m., R112 stated staff had not offered to help them get set up to brush their teeth,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident could smoke safely for 1 of 1 resident (R10) reviewed for safe smoking.Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 was cognitively intact and had no rejections of care. In addition, R10's MDS identified he required set up for eating and was dependent on staff for activities of daily living.R10's Diagnosis Report dated 6/26/26, identified R10 had diagnoses which included heart failure (a condition where the heart muscle is too weak or too stiff to pump blood efficiently), lymphedema (a chronic condition characterized by the abnormal buildup of protein-rich lymph fluid, which causes swelling [edema] in the body's soft tissues), cellulitis of left finger, acquired absence of left finger(s), burn of unspecified degree of multiple sites of left and right wrist and hand, diabetes mellitus, open wound of left middle finger, open wound of left ring finger.R10's Medication Review Report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure Enhanced Barrier Precautions (EBP) protocols were followed for 1 of 1 resident (R103) reviewed for infection control.Findings include:R103's quarterly Minimum Data Set (MDS) dated [DATE], identified R103 was cognitively intact.R103's diagnoses included diabetes mellitus, renal insufficiency, neurogenic bladder, hypertension, anemia, arthritis, anxiety, and depression.R103's care plan dated 6/17/26, identified the resident was on EBP related to a suprapubic (SP) catheter and chronic wounds, and directed care staff to follow EBP and to utilize gowns and gloves for all personal care. R103's provider orders dated 12/11/25, included SP catheter cleansing and maintenance for neuromuscular dysfunction of bladder.During an observation on 6/24/26 at 12:58 p.m., R103's door had a sign indicating R103 was on EBP. The sign instructed staff to wear a gown and gloves for high-contact resident care activities, including dressing and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure residents did not have to share a living space with a resident (R72) who would not shower or change clothing. This deficient practice affected 3 of 3 residents (R52, R65, R44) reviewed for environment.Findings include:R72's quarterly Minimum Data Set (MDS) dated [DATE], identified he had diagnoses which included anemia, heart disease, hypertension, arthritis, depression, panlobular emphysema (an irreversible type of chronic obstructive pulmonary disease [progressive, incurable lung disease that blocks airflow and makes breathing difficult]), hypomagnesemia (a low level of magnesium in the blood), cannabis use, and gastroesophageal reflux disease (when stomach acid flows back up into the esophagus and causes heartburn). In addition, R72's MDS identified he was cognitively intact, had no rejections of care and was independent with activities of daily living (ADLS) including personal hygiene.R72's Medication Review Report dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure residents right to leave the facility was honored for 2 for 3 residents (R1, R2) reviewed who had physicians orders restricting their rights to a leave of absence.R1's admission Record indicated she admitted to the facility on [DATE]. Diagnoses include type 2 diabetes mellites (DMII), infection of left hip, pain, weakness and gait abnormalities.R1's care plan dated 2/10/24, indicated she was at low risk for elopement. The care plan identified substance abuse/dependence as evidenced by resident having alcohol and drug paraphernalia/admitting to substance use and indicated leave of absence (LOA) privileges revoked per physician.R1's Physician Order Report dated 10/20/25, identified the following order dated 7/10/25: Revoked privileges of LOA. Resident not allowed to leave facility per provider.R2's admission Record indicated he admitted to the facility 2/13/25. Diagnoses included: depression, head laceration, anemia, tobacco use and alcohol…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 24 citations
- Potential for harm · D2025-12-04 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure appropriate discharge rights for 1 of 3 residents (R1) who was discharged from the facility following a leave of absence. R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis include DMII, infection of left hip, pain, weakness and gait abnormalities.R1's care plan dated 2/10/24 indicated she was at low risk for elopement. The care plan identified substance abuse/dependence as evidenced by resident having alcohol and drug paraphernalia/admitting to substance use and indicated leave of absence (LOA) privileges revoked per physician.R1's Physician Order Report dated 10/20/25, identified the following order dated 7/10/25: Revoked privileges of LOA. Resident not allowed to leave facility per provider.R1's Resident Discharge Summary indicated she discharged from the facility 10/20/25. the summary identified R1's discharge location as other and indicated, unable to meet her needs.R1's Progress Notes indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-17 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure biologic medications were labeled with a pharmacy label indicating the resident's name and prescription information and to ensure biologic medications were destroyed after their beyond-use-date (BUD) in 1 of 3 medication carts reviewed for medication labeling and storage. This had potential to impact any resident receiving insulin in the Harbor Light community. Findings include: During an observation and interview on [DATE] at 1:45 p.m., in the Harbor Light community, licensed practical nurse (LPN)-D confirmed there was an insulin aspart 70/30 mix pen in the top drawer of the medication cart. LPN-D stated she was not aware of who this belonged to, they did go through the carts regularly for expired or beyond use medication. LPN-D confirmed with a printed resource on the medication cart indicating insulin aspart was good for 28 days after opening. LPN-D stated the insulin will be destroyed. During an interview on [DATE] at 3:56…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and documents review the facility failed to remove medications after each use for a resident not approved to keep at bedside. This affected 1 of 1 resident (R33) reviewed for self-administration of medication. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], identified R33 had intact cognition. Diagnosis included dementia and Parkinson's disease. R33's Self Administration of Medication (SAM) assessment dated [DATE], identified R33 could not identify expiration date of each medication and to continue plan of care. R33's SAM assessment dated [DATE], identified R33 could not identify expiration date of each medication and to continue plan of care. The SAM also identified either R33 did not want to self-administer medications or was unable to determine. R33's care plan undated, lacked documentation related to R33's SAM assessment. During observation on 4/14/25, at 2:16 p.m., a bottle of nystatin powder with R33's name on it was noted on the bedside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain respect and dignity for personal space for 2 of 3 resident's (R31, R55) reviewed who had their room searched without consent. Findings include: R31's clinical admission undated, indicated R31 was her own responsible party. R31's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had intact cognition. Diagnoses included heart failure, anxiety and depression. R31's care plan last updated 5/31/24, indicated resident had a behavior problem related to false accusations and blaming others of mistreatment. One documented trigger for behavior listed under interventions was room searches. R31's active order list dated 7/29/24, indicated search room in pairs after each leave of absence, family visit, and as needed. Review of R31's progress notes from 11/1/24 to 4/16/25 indicated the following: - 4/14/25 at 5:54 p.m., writer did a room search with social services and administrator after visitor left. Resident refused search…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a resident's room was clean and homelike for 1 of 3 residents (R45) reviewed for environment. Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], identified an admission date of 10/25/24, and primary diagnosis as orthopedic care following surgical amputation of the right lower leg. During observation and interview on 4/14/25 at 4:02 p.m., R45 stated his room was too dark, there were stains and holes in the walls, one of the blinds wouldn't raise or lower and these things bothered him. On observation, there were several screw holes in the wall between the two windows, and multiple streaks of a brownish-black substance four to five inches long on the wall behind his bed and chair that bothered him. The light over the sink area had droplets of a brown, dried substance on it, and a glob of something brown and thick of about 1 inch long on the front of the light. There was one light over the sink, one over his bed, and one over his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 4 residents (R65, R86) reviewed for accuracy of assessments. Findings include: R65: R65's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of morbid obesity. Section N of the MDS identified R65 received one injection of insulin during the assessment period. R65's provider orders dated 1/10/24, identified Trulicity (an injectable non-insulin medication used to improve blood sugar levels) one time weekly. R65's medication administration record for February 2025 identified Trulicity administration on 2/21/25. During an interview on 4/16/25 at 10:35 a.m., registered nurse (RN)-B confirmed the only injectable medication R65 was taking between 2/17 and 2/24/25 would have been Trulicity. During an interview on 4/17/25 at 10:42 a.m., RN-E confirmed she was the nurse responsible for R65's MDS of 2/24/25. RN-E stated her process was to review the resident's orders and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure fluid restrictions were monitored for 2 of 2 residents (R5, R31) reviewed for quality of care. In addition, the facility failed to notify the provider upon resident refusal of medication and when a resident's weight went outside prescribed parameters for 1 of 1 resident (R45). Findings include: R5: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 had intact cognition. Diagnoses included anemia and end stage renal disease. R5 currently received hemodialysis. R5's care plan dated 11/14/24 indicated a risk for altered fluid balance related to (R/T) kidney disease and heart disease: 1200 milliliter (ml) fluid restriction. R5's provider orders dated 3/15/25 indicated a 1200 ml fluid restriction to be documented on each shift. Review of R5's medical record indicated the following: - On 4/9/25 1580 ml of fluid was received - Fluid intake documentation was missed on 3 shifts, NA was charted on 3 shifts and an X was charted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure weekly skin checks were performed for a resident who developed a pressure ulcer in the facility, to ensure the resident care plan included the presence of actual pressure ulcers, with individualized interventions based on assessment to include turning and repositioning frequency, the presence of integrated wound therapies, an actual wound infection, and manufacturer's recommendations for checking inflation of a Roho (specially designed inflatable wheel chair cushion) for 1 of 2 (R21) residents reviewed for pressure ulcer care. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of multiple sclerosis (MS), quadriplegia, muscle weakness and unstageable pressure wound to left buttock. The MDS identified R21 had limited range of motion in the upper and lower extremities and needed maximum assistance with bed mobility. The 3/6/25 MDS indicated a risk for pressure sores but no actual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0700 — isolatedTry 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess prior to resident use of bed rails for 1 of 1 resident (R52) reviewed for bed rail use. Findings include: The Guidance for Industry and Federal Drug Administration (FDA) Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 3/10/24, indicated a comprehensive assessment to prevent entrapment should be looked at when bedrails are considered for a resident. The comprehensive assessment included seven zones to look at and take measurements of which included the following: Zone 1: Within the rail Zone 2: Under the rail, between the rail supports or next to a single rail support. Zone 3: Between the rail and the mattress. Zone 4: Under the rail and the mattress. Zone 5: Between split bed rails. Zone 6: Between the end of the rail and the side edge of the head or footboard. Zone 7: Between the head or foot board and the mattress end. R52's quarterly Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure indications for use were identified for ordered medications in 1 of 5 residents (R26) reviewed for unnecessary medication. Findings include: R26's admission Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition with diagnoses of dementia, muscle weakness, Wernicke's encephalopathy (neurological condition caused by a lack of thiamine), hypertension, hypothyroidism, urinary incontinence, type 2 diabetes, and alcohol use in remission. R26's orders reviewed on 4/15/25, identified the following medication orders: -aspirin low dose oral tablet delayed release 81 mg- give one tablet by mouth once a day for analgesics- nonnarcotic -atorvastatin 40 mg- give one tablet by mouth at bedtime for antihyperlipidemics, chemicals -finasteride oral tablet 5 mg- give one tablet by mouth once a day for genitourinary agents, miscellaneous, dermatologicals -levothyroxine oral tablets 112 micrograms (mcg)- give one tablet by mouth once a day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure behavior monitoring and gradual dose reduction (GDR) or justification of continued use was identified for 1 of 5 (R5) residents reviewed for unnecessary medication who were on a psychotropic medication. In addition, the facility failed to ensure ordered medication had an indication for use for 2 of 5 residents (R23, R26) reviewed for unnecessary medication. Findings include: R5: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had intact cognition and had diagnoses that included anxiety, depression, and post-traumatic stress disorder. R5's care plan dated 4/17/25, indicated a history of depression related to disease processes and family history. Interventions included monitor resident for signs/symptoms of depression that included hopelessness, anxiety sadness, insomnia, anorexia, verbalizing negative statements. R5's physician orders dated 3/3/25, indicated, Buspar 15 milligrams (mg) three times a day (TID) by mouth for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to perform appropriate hand hygiene while doing a brief change for 1 of 1 resident (R52) reviewed for infection control. In addition, the facility failed to ensure a shared glucometer was cleaned and sanitized according to manufacturer's instructions for 1 of 1 resident (R78) reviewed for blood sugar testing, and to ensure hand hygiene and gloves were in place during eye drop administration for 1 of 4 residents (R64) reviewed for medication administration. Findings include: R52: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 had moderate to severe cognitive impairment. Diagnoses included dementia, Huntington's disease and depression. Section G- Functional Abilities and Goals indicated R52 had impairments to both sides of the upper and lower body and was dependent for toileting hygiene. The MDS indicated R52 was always incontinent of both bowel and bladder. During observation on 4/15/25 at 1:38 p.m., nurse assistant (NA)-A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program 1 of 1 resident (R52) reviewed for bed rail safety. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 had moderate to severe cognitive impairment. Diagnoses included dementia, Huntington's disease and depression. Section G- Functional Abilities and Goals indicated R52 had impairments to both sides of the upper and lower body and was dependent for all mobility needs. R52's care plan dated 4/17/25, indicated a physical mobility impairment related to Huntington's disease and intervention included assist resident to perform movements/tasks. R52's care plan last updated 4/15/25, indicated an activity of daily living self-care need with interventions that included resident is an extensive assist of two staff to turn and reposition in bed. A bedrail in place to promote independence. On 4/14/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-28 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure the 56 residents with personal funds accounts (including R11, R14, R17, R20 and R44) deposited with the facility had access to the personal funds after hours and on weekends. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact. On 5/20/24 at 2:06 p.m., R11 stated she can only take money out or put money in between 1:30 p.m. and 3:30 p.m during the week. R11 further stated nobody is here on the weekend so we do money stuff during the week. R14's quarterly MDS dated [DATE], indicated R14 was cognitively intact. On 5/20/24 at 5:10 p.m., R14 stated he can access his money during the week and has to plan ahead to have the money he needs. R17's significant change MDS dated [DATE], indicated R17 was cognitively intact. On 5/20/24 at 5:11 p.m., R17 stated she can only get money from her account between 1:30 p.m. and 3:30 p.m. R17 further stated this is very inconvenient, used to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-28 · tag F0729 — patternVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to monitor nurse aid registry for inactive nursing assistants (NA) during their employment and allowed them to continue to work directly with residents after their registry had become inactive for 1 of 6 NAs reviewed. This had the potential to affect all residents in the facility whom the NA may care for. Findings include: Review of NA-J's personnel file identified a hire date of 12/7/23. A search on the Minnesota Nurse Aid Registry revealed NA-J had an inactive status as of 5/16/24. Review of facility schedule revealed NA-J was on the schedule and actively worked day shifts during the survey on May 20th, 21st, 22nd, 23rd of 2024. During an interview on 5/28/24 at 11:04 a.m., the facility administrator stated the staffing agency and the facility both check the NA registry on hire and the agency was supposed to contact the facility with upcoming expirations. The administrator was not aware NA-J no longer had an active registration.
- Potential for harm · Ecited before2024-05-28 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure personal protective equipment (PPE) was used for 1 of 2 residents (R95) when providing care for residents in enhanced barrier precautions. In addition, staff failed to perform hand hygiene during medication administration for 1 of 4 residents (R61) observed during medication administration. Findings include: R95's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of non-Alzheimer's dementia, constipation, and urinary retention. R95 was dependent on staff for toileting transferring and hygiene and was incontinent of bowel and bladder frequently. R95's care plan dated 4/4/24, identified an actual impairment to skin integrity as evidenced by a vascular wound to left lower extremity. A sign, Enhanced Barrier Precautions, was on the outside of R95's door and identified providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update the provider for a resident with significant weight loss for 1 of 6 residents (R56) reviewed for nutrition and weight loss. Findings include: R56's quarterly Minimum Data Set (MDS) dated [DATE], identified a cognitive assessment was not successful and diagnoses of dementia without behavior and gastroesophageal reflux disease (GERD). R56 needed partial assist with eating, had no chewing or swallowing issues and had non-prescribed weight loss. R56's provider orders dated 4/15/24, identified an order for a regular diet with ground meat and regular liquids. On 5/22/24 R56 received an order for a house supplement three times per day. R56's care plan dated 9/13/22, identified a problem statement for nutrition with a goal to maintain 163 within five percent with no signs or symptoms of malnutrition and consuming at least 50 percent of meals. Interventions included getting weight per policy, adaptive equipment as needed, provide bowls with each food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-28 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R3) reviewed who remained in the facility after their Medicare part A covered services ended. Findings include: R3's Centers for Medicare and Medicaid Services (CMS)-10123 form dated 3/4/24, identified R3's Medicare last covered day (LCD) as 3/7/24. R3's medical record lacked evidence a SNFABN was provided to R3 to explain the estimated cost per day or provide rationale of the extended care services or items to be furnished, reduced, or terminated. During an interview on 5/22/24 at 12:47 p.m., the business manager (BM) stated R3 did not receive an SNFABN. During a follow-up interview on 5/23/24 at 11:07 a.m., the BM confirmed R3 had remaining Medicare part A days, and indicated when R3's Medicare Part A covered services were no longer required, R3 should have been issued a SNFABN. During an interview on 5/28/24 at 12:40 p.m., the administrator stated when a resident is discharged from a Medicare part A service and no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-28 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to correctly code section B of the Minimum Data Set (MDS) for 1 of 1 resident (R67) reviewed for MDS accuracy. Findings include: R67's significant change MDS dated [DATE], identified diagnoses which included type 2 diabetes mellitus with stable proliferative diabetic retinopathy (a serious complication of diabetic retinopathy which can lead to total vision loss), bilateral posterior synechiae (abnormal adhesions between the iris and the lens or cornea), bilateral iridocyclitis (an inflammation of the vascular layer of the eye and ciliary body), and cataract (clouding of the normally clear lens of the eye) with neovascularization of right eye (new blood vessels grow in a cataract which can sometimes lead to vitreous hemorrhage (blood leaks into the vitreous humor which can cause vision problems). R67's significant change MDS dated [DATE], section B identified R67's vision as adequate. R67's care plan dated 4/12/23, identified R67 had a vision impairment.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-28 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure standard practices for safe medication administration were utilized for 1 out of 4 residents (R61) who were observed for medication pass. Findings include: R61's quarterly Minimum Data Set (MDS) dated [DATE], indicated R61 had severe cognitive impairment with the diagnoses of major depression, cognitive impairment, anxiety, osteoarthritis, and diabetes. R61's Order Summary Report dated 5/28/24, included the active order: -Nystatin external powder 100000 Unit/GM [gram] [antifungal medication used to treat fungal infections of the skin] apply to groin and abdomen two times a day until healed. During a medication observation on 5/22/24 at 3:39 p.m., registered nurse (RN)-D had two medication cups, one with powder and one with cream. RN-D entered R61's room, sanitized hands, and applied gloves. R61 lowered their pants and RN-D cleansed and dried R61's groin area. RN-D removed their gloves, applied new gloves, and applied Nystatin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure orders were followed as written for 1 of 3 residents (R67) reviewed for heart failure and failed to administer medications as ordered for 1 of 4 residents (R81) reviewed for medication administration. The facility further failed to accurately document behaviors related to as needed medication administration for behaviors for 1 of 1 resident (R71) reviewed for behaviors. Findings include: R67: R67's significant change Minimum Data Set (MDS) dated [DATE], identified diagnoses which included type 2 diabetes mellitus, sequela of cerebral atheroscerosis (stroke), hypertension, and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). In addition, R67's MDS identified him as cognitively intact. R67's care plan did not address his heart failure. R67's Order Summary Report dated 5/28/24, directed staff to report to the Essentia cardiology heart failure program any weight gains or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to secure oxygen tanks in a resident room for 1 of 1 resident (R75) reviewed for accidents. Findings include: R75's significant change Minimum Data Set (MDS) dated [DATE], identified diagnoses which included morbid obesity, chronic respiratory failure, insomnia, and chronic fatigue. In addition, R75's MDS identified R75 as cognitively intact and on oxygen therapy. R75's Order Summary Report dated 5/28/24, identified oxygen via nasal cannula at four liters per minute every shift. On 5/20/24 at 1:40 p.m., in R75's room four oxygen tanks were observed behind her recliner, two were secured in stands and two were free standing. All four oxygen tanks were full. R75 stated the tanks were hers and were delivered to her room by the oxygen company. On 5/20/24 at 1:45 p.m., licensed practical nurse (LPN)-B and nursing assistant (NA)-B entered the room and verified the tanks were full and should not be free standing. NA-B went immediately to get stands to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2026-06-26 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure that mail was delivered to residents on Saturdays. This had the ability to affect all residents who received mail to the facility.Findings include: R101's annual Minimum Data Set (MDS) dated , 5/21/26, identified R101 as cognitively intact. R85's annual MDS dated [DATE], identified R85 as cognitively intact. During interview on 6/25/26 at 9:57 a.m., R101 stated that if mail comes on Saturday, it is not being delivered until Monday. R85 confirmed that mail gets delivered to the front desk on Saturday and is sorted and delivered on Monday. During interview on 6/25/26 10:54 a.m., the front desk receptionist and business office manager (BOM)-A stated they deliver to residents during the week. On Saturday if they are expecting something for mail, they can come and grab it, otherwise we go though it on Monday and deliver it out through the facility. Facility policy, Mail and Electronic Communication, undated, indicated mail and packages will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-04-17 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure the most recent state agency (SA) survey results were readily accessible and post signage and/or notice of the inspection reports within the campus. This had potential to affect all 87 residents, visitors, and their families who could wish to review the information. Findings include: During an observation and interview on 4/14/25 at 12:35 p.m., no posted signs were available for survey results. The receptionist (O)-H stated that the survey results were kept in a green binder, located to the left of the front desk. The binder was stored on a plastic shelf affixed to the counter and secured with a cable; as a result, survey results were reviewed at the front desk rather than in private. The binder was organized with plastic tabs labeled for the years 2023 and 2022, with the most recent survey results dated June, 2023. During an interview on 4/14/25 at 4:31p.m., O-H stated that the administrator was responsible for maintaining the binder containing the state survey results. During an interview on 4/15/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$132,398 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $122,175 — penalty dated 2024-05-28
- $10,223 — penalty dated 2024-04-20
- Medicare payment denial — starting 2024-06-26 for 10 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EPHRAM LAHASKY — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 2.1 | +1.9 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 21 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CBAY BAYSHORE HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 03/31/2016 |
| MB DULUTH HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 21% | since 03/31/2016 |
| KATZ, ABE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 21% | since 03/31/2016 |
| BABBITT, DON | Individual | W-2 MANAGING EMPLOYEE | — | since 03/31/2016 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245227. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.