Bay Harbor Senior Living of La.
Bay Harbor Senior Living of La is Grade C, ranked in the top 48% of Minnesota memory care with 1 MDH citation on record; last inspected Sep 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Bay Harbor Senior Living of La has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Bay Harbor Senior Living of La's record and state requirements.
The most recent Minnesota Department of Health inspection on September 26, 2025 found zero deficiencies across all standards — can you walk us through the facility's internal audit process that helps maintain compliance, and how often do you conduct self-assessments before MDH surveys?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
One complaint was filed with MDH during the inspection period on record — can you share whether that complaint was substantiated, what the subject matter involved, and what corrective steps the facility documented in response?
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This facility holds an Assisted Living Facility with Dementia Care license under Minnesota Statutes chapter 144G — can you provide a copy of the written dementia care program and explain how it addresses the specific memory care needs of residents across your 86 licensed beds?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
2 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-09-26Annual Compliance VisitNo findings
Plain-language summary
A follow-up survey was conducted December 8-11, 2025, to check on correction orders issued after a September 26, 2025 inspection at Bay Harbor Senior Living of La Crescent, which serves 76 residents including 65 receiving dementia care. Three correction orders were reissued during the follow-up visit related to food service requirements. No immediate fines were assessed, but the facility must document actions taken to comply with these orders.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of t he violati ons ; however, no immediate fines are assessed for this survey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm We urge you to review these orders carefully. If you have questions, please contact Jodi Johnson at An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Bay Harbor Senior Living of La Crescent December 29, 2025 Page 2 You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: Jodi.Johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 CLN PRINTED: 12/ 29/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 33651 12/ 11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1384 COUNTY ROAD 25 BAY HARBOR SENIOR LIVING OF LA CRESCENT LA CRESCENT, MN 55947 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 000} Initial Comments {0 000} ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE- ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL33651016- 1 far-left column entitled "ID Prefix Tag. " The state Statute number and the On December 8, 9, 2025, and December 11, corresponding text of the state Statute out 2025, the Minnesota Department of Health of compliance is listed in the "Summary conducted a follow-up survey at the above Statement of Deficiencies" column. This provider to follow-up on orders issued pursuant to column also includes the findings which a survey completed on September 26, 2025. At are in violation of the state requirement the time of the survey, there were 76 residents; after the statement, "This Minnesota 65 receiving services under the Assisted Living requirement is not met as evidenced by." with Dementia Care license. As a result of the Following the evaluators ' findings is the follow-up survey, the following orders were Time Period for Correction. reissued: 1420, 1640, 1650. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. {0 480} 144G. 41 Subdivision 1 Subd. 1a (a-b) Minimum {0 480} SS= F requirements; required food services LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6HXS12 If continuation sheet 1 of 12 PRINTED: 12/ 29/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 33651 12/ 11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1384 COUNTY ROAD 25 BAY HARBOR SENIOR LIVING OF LA CRESCENT LA CRESCENT, MN 55947 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 480} Continued From page 1 {0 480} (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626. 0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60- mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626. 0545, item A, kick plates that are not removable or cannot be rotated open are allowed unless the facility has been issued repeated correction orders for violations of Minnesota Rules, part 4626. 1565 or 4626. 1570; (3) notwithstanding Minnesota Rules, part 4626. 0685, item A, the facility is not required to provide integral drainboards, utensil racks, or tables large enough to accommodate soiled and clean items that may accumulate during hours of operation provided soiled items do not contaminate clean items, surfaces, or food, and clean equipment and dishes are air dried in a manner that prevents contamination before storage; (4) notwithstanding Minnesota Rules, part 4626. 1070, item A, the facility is not required to install a dedicated handwashing sink in its existing kitchen provided it designates one well of a two-compartment sink for use only as a handwashing sink; (5) notwithstanding Minnesota Rules, parts 4626. 1325, 4626. 1335, and 4626. 1360, item A, existing floor, wall, and ceiling finishes are STATE FORM 6899 6HXS12 If continuation sheet 2 of 12 PRINTED: 12/ 29/ 2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 33651 12/ 11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1384 COUNTY ROAD 25 BAY HARBOR SENIOR LIVING OF LA CRESCENT LA CRESCENT, MN 55947 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 480} Continued From page 2 {0 480} allowed provided the facility keeps them clean and in good condition; (6) notwithstanding Minnesota Rules, part 4626. 1375, shielded or shatter- resistant lightbulbs are not required, but if a light bulb breaks, the facility must discard all exposed food and fully clean all equipment, dishes, and surfaces to remove any glass particles; and (7) notwithstanding Minnesota Rules, part 4626. 1390, toilet rooms are not required to be provided with a self- closing door. This MN Requirement is not met as evidenced by: Not reviewed during this survey {0 775} 144G. 45 Subd. 2. (a) Fire protection and physical {0 775} SS= F environment Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: Not reviewed during this survey {01420} 144G. 62 Subd.
2024-07-15Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that the facility was responsible for neglect that resulted in a resident's death. After the resident returned from hospitalization with increased diuretic medication, she was found with her head and neck trapped between a siderail and mattress, and the medical examiner determined she died from positional asphyxia. The facility did not have a system in place to ensure the siderail was properly positioned or maintained, and did not adjust monitoring or safety measures following the resident's hospital discharge and medication changes.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the facility allowed a siderail to be used which the resident became entrapped in and died. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility did not have a system in place to ensure the resident’s side rail was placed properly nor to ensure it was maintained in that condition. After returning from a hospital stay with changes to the resident’s medication regimen, the resident was found dead with her head and neck lodged between the siderail and her bed. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator also contacted law enforcement, the medical examiner’s office, emergency response services, and a family member. The investigation included a review of the resident’s facility bedrail policy, progress notes, death record, autopsy report, coroner photos, call pendant log, staff schedule, resident service plan, and recent hospital record. Also, the investigator made an onsite visit and observed bedrails in use at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included osteoarthritis (degenerative joint disease), congestive heart failure (heart cannot pump blood well enough), and polyneuropathy (damage to multiple nerves). The resident’s service plan included assistance with medication administration, compression stockings, and monitoring of vital signs. The resident’s assessment indicated she used a four-wheel walker and was independent with transfers and getting in and out of bed. The facility incident report indicated one morning an unlicensed caregiver entered the resident’s apartment and found the resident with her head and neck stuck between the mattress and the siderail. The resident was described as unresponsive. The same document indicated 911 was called and the unlicensed caregiver raised the resident’s head out form the siderail and mattress. Approximately three months prior to the resident’s death the facility completed a siderail assessment which indicated the resident had a history of falls and difficulty with bed mobility and going from a lying to position to a sitting position in bed. The assessment indicated the resident used a siderail for positioning and support. The same assessment indicated positive and negative aspects of siderail use had bene discussed with the resident although the document did not indicate what the specific risks were to the resident. The same form listed under recommendations bilateral side rails. The resident’s monthly electronic medication administration (EMAR) indicated the facility administered furosemide (a diuretic) 20 milligrams (mg) twice day for water retention. The resident received this medication up until a hospitalization that occurred about 10 days prior to her death. Ten days prior to her death, the resident was hospitalized due to shortness of breath, peripheral edema (leg swelling caused by excess fluid in the tissues), weight gain, and decreased activity tolerance. The resident was in the hospital for about four days and then returned to the facility with an increase in her diuretic medication on the fifth day. The facility did an assessment upon return from the hospital and made note of the recent hospitalization. This assessment indicated resident used half bed rails as a supporting resource for getting in and out of bed. The same assessment indicated the resident was at moderate risk for falls. The assessment did not indicate the increase of the resident’s diuretic or additional need for monitoring. For the five days prior to the resident’s death the EMAR indicated the facility administered the increased dose of furosemide 40 mg twice a day. Three days prior to the resident’s death the facility completed a monthly check which included a set of vital signs which indicated a blood pressure of 104/70 and a pulse of 62. The same document indicated the resident had pain in her feet, legs, and knees but included no other information. A review of the resident’s medical record identified no other follow-up to these findings. The resident’s progress notes on the morning of she died indicated the cause of her death was “not sure” while also indicating she was found with her head stuck in her siderail. The resident’s autopsy indicated she had multiple contusions along the neck and the left neck furrow while noting the resident was found with her neck “compressed” between a siderail and a bed. The same document included a description of “blunt force” injuries to the resident’s neck and torso. According to this document, the resident died as a result of positional asphyxia. The resident’s death record listed the immediate cause of death as positional asphyxia [suffocation]. During an interview, an unlicensed caregiver stated the morning of the incident she entered the resident’s apartment, went to collect the diabetic supplies in the resident’s bathroom and when she walked into the bedroom the resident was not on the bed but could see her head was on the mattress. The unlicensed caregiver then walked around the bed and found the resident’s body off the bed and her head and neck caught between the siderail and mattress. The unlicensed caregiver stated she felt the resident’s face which felt cold to touch and tapped her cheek and said her name with no response. The unlicensed caregiver stated the resident was facing towards the window with her head slightly turned and body twisted but with her head trapped. The unlicensed caregiver stated she lifted and released the resident’s head from the rail and then called 911. She said the siderail was located on the right-hand side of the bed which is the side the resident uses to get in and out of bed. During an interview, a manager stated the siderails are not managed or maintained by maintenance. The manager stated when residents move in the facility hires a moving company to help and could not say who put the siderail on the resident’s bed at the time of the move. The manager stated he was not personally familiar with the actual siderail in the resident’s room. During an interview, a nurse stated the resident had her own single bed and could not state who installed the siderail. The siderail was located on the right side of the bed only and was used by resident for bed mobility and to assist resident to a sitting position. The nurse stated there was not any orders for the siderails. The nurse stated the facility assessed siderails quarterly and looked at guidelines of the Food and Drug Association but not at the manufacturer’s recommendations. While discussing the assessments, the nurse stated they did not indicate if the siderails were in working order. The nurse stated the facility did not have the manufacturer’s instructions which was not consistent with the facility’s written policy. She stated if the resident or resident’s family member or representative requested siderails the facility verbally goes through the risks and benefits with them. During an interview with a family stated the bed was a twin-size bed with frame, box spring, and mattress and had two handrails on it. She stated there were two siderails on the bed and the resident owned the one on the right side, but she was not sure how the one on the left side came to be in place. The resident also used a step stool on the right side of the bed where the resident got in and out of bed which was used because the resident was short and needed a stool to get in and out of the bed. An image provided by the medical examiner office showed the resident deceased on the floor on the right side of the bed (from the head of the bed perspective) with the siderail on the same side of the bed visible. The image also shows another siderail near the foot of the bed on the left side of the bed. A review of the resident’s medical record showed no reference to the siderail at the foot of the bed on the left side.
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