1601 St. Louis Avenue, Duluth, MN 55802 · St. Louis County · (218) 727-8651
140 certified beds, about 98 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1979
CMS Care Compare ratings, data as of September 1, 2026 · CCN 245227 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 26, 2026, inspectors cited 10 health deficiencies (the Minnesota average is 7.1, the national average 9.2).
Of 37 health citations since April 2024, 3 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 2 fines totaling $132,398 in the last three years; the largest was $122,175, and the latest is dated May 28, 2024.
Nurses and nurse aides worked 3.56 hours per resident per day, against 4.19 across Minnesota and 3.86 nationally. Registered nurses accounted for 0.83 of those hours.
58.0% of nursing staff left within the year CMS measured (Minnesota average 42.2%).
CMS links it to Ephram Lahasky, an affiliated group of 22 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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).
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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. [...]
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
Inspectors wroteBased 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.
26 fire safety citations on file: 10 on June 26, 2026, 6 on April 17, 2025, 10 on May 28, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| May 28, 2024 | Fine | $122,175 |
| May 28, 2024 | Payment Denial | 10 days from June 26, 2024 |
| April 20, 2024 | Fine | $10,223 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Minnesota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.56 | 4.19 | 3.86 |
| Registered nurses | 0.83 | 1.06 | 0.69 |
| All nursing staff on weekends | 3.12 | 3.71 | 3.42 |
| Nurse aides | 2.52 | ||
| Licensed practical nurses | 0.21 | ||
| Nursing staff turnover (share who left in a year) | 58.0% | 42.2% | 45.8% |
| Registered nurse turnover | 30.0% | 38.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.06 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.74 on weekdays and 3.12 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 45.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.93 in April to June 2025 to 3.56 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.56 | 0.83 | 3.74 | 3.12 | 45.2% | 0 of 90 | 98 |
| Oct to Dec 2025 | 3.80 | 0.88 | 4.01 | 3.28 | 44.5% | 0 of 92 | 91 |
| Jul to Sep 2025 | 3.80 | 0.90 | 4.04 | 3.19 | 48.1% | 0 of 92 | 92 |
| Apr to Jun 2025 | 3.93 | 0.94 | 4.16 | 3.37 | 52.8% | 0 of 91 | 87 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Minnesota, Jan to Mar 2026 | 4.19 | 1.05 | 4.38 | 3.73 | 5.2% | 0.8% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Minnesota, all employers | |||
| CNAs (nursing assistants) | $22.44 | $19.39 to $23.72 | 29,120 |
| LPNs and LVNs | $30.65 | $28.83 to $34.26 | 12,840 |
| Registered nurses | $48.80 | $42.76 to $55.17 | 70,110 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Minnesota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.3 | 18.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.6 | 1.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.8 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.7 | 4.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.9 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.2 | 20.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.8 | 5.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 32.0 | 17.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 27.4 | 23.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 24.6 | 14.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.8 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.7 | 1.9 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Bayshore Residence and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (61.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
61.2% this home
No different from the national rate
US median of homes 51.5% · Minnesota: 66 better, 14 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 39 eligible stays.
9.8% this home
No different from the national rate
US median of homes 10.7% · Minnesota: 0 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 58 eligible stays.
6.9% this home
No different from the national rate
US median of homes 7.1% · Minnesota: 2 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 29 eligible stays.
54.0% this home
Median of homes: Minnesota57.8% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 37 residents counted.
0.0% this home
Median of homes: Minnesota0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 44 residents counted.
11.7% this home
Median of homes: Minnesota2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 44 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Minnesota98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 13 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: DULUTH NURSING AND REHABILITATION CENTER LLC. CMS links this home to Ephram Lahasky, a group of 22 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Cbay Bayshore Holdings LLC | 5% or greater direct ownership interest | Organization | 13% | 03/31/2016 |
| Mb Duluth Holdings LLC | 5% or greater direct ownership interest | Organization | 21% | 03/31/2016 |
| Katz, Abe | 5% or greater direct ownership interest | Individual | 21% | 03/31/2016 |
| Babbitt, Don | W-2 managing employee | Individual | 03/31/2016 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Minnesota. NursingHomeClear cannot take or act on complaints.