Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BAYSHORE RESIDENCE AND REHABILITATION CENTER
DULUTH, MN · 140 certified beds · Last Life Safety survey June 26, 2026
CMS Certification Number 245227 · first certified January 1979
Ownership
Operated by EPHRAM LAHASKY · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
26 citations — more than 91% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 10 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was June 2026. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 28, 2024 | 10 |
| April 17, 2025 | 6 |
| June 26, 2026 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2026-06-26 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-06-26 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2026-06-26 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-04-17 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 2 | 2026-06-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-06-26 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2025-04-17 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2024-05-28 |
What the citations cover
- Smoke Deficiencies 11
- Egress Deficiencies 5
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Electrical Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 26, 2026 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 7, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has plan of correction (August 7, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has plan of correction (August 7, 2026) |
April 17, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 20, 2025) |
May 28, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (July 6, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (June 21, 2024) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (June 21, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.