Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Shore Health & Rehab Facility during CMS and state inspections, most recent first.
A resident with dementia but intact cognition, who depended on staff for ADLs, had a dementia medication (donepezil) discontinued following a pharmacist’s recommendation and a physician’s order. Facility policy required notifying the resident, consulting the physician, and informing the resident’s representative when treatment was altered, including discontinuation of medications. However, there was no documentation that the resident or representative was informed of the recommendation or the discontinuation, and the representative later reported learning of the change about two months afterward and being very upset. The DON acknowledged that the representative had not been notified at the time of the medication change.
The facility failed to provide mechanically altered diets as prescribed, serving regular wheat rolls and peas instead of puree bread and cooked sliced carrots to residents on a level six soft and bite-sized diet. Staff were not fully trained on using diet spreadsheets, leading to incorrect food items being served.
The facility failed to maintain proper sanitation in the kitchen, with the dishwashing machine not reaching required temperatures and staff not performing proper hand hygiene while plating and serving meals. The dish machine consistently failed to reach 180°F, and staff were unaware of proper procedures, leading to potential contamination of dishes and utensils.
The facility failed to assess, accurately document, and provide treatment for a resident with pressure ulcers. The resident, who had a history of dementia, chronic kidney disease, and diabetes, was observed with an open wound on the coccyx area, causing significant pain. The facility's documentation was inconsistent, and the physician was not notified about the reopened wound. Staff interviews revealed a lack of consistent communication and understanding regarding the resident's wound care.
The facility failed to ensure timely and adequate pain management for two residents, leading to significant discomfort and distress. One resident with dementia and a history of a pressure injury did not receive PRN Tramadol as ordered, and pain monitoring was inadequately documented. Another resident with hemiplegia and other conditions had an incomplete care plan and inconsistent pain documentation, resulting in ineffective pain management.
A resident was not provided with appropriate non-pharmacological interventions for behaviors, and the facility failed to monitor for side effects and consistently document behaviors to justify the use of psychotropic medications. Observations and staff interviews revealed a lack of timely assistance and documentation, contrary to the facility's policy.
The facility failed to maintain proper infection control on the Parkview unit by not disinfecting mechanical lifts and vital signs equipment after use. Additionally, a contract pharmacist did not follow hand hygiene protocols during a vaccination clinic, including not changing gloves or performing hand hygiene between tasks.
Failure to Notify Resident Representative of Discontinued Dementia Medication
Penalty
Summary
The facility failed to notify a resident’s representative of a significant medication change, specifically the discontinuation of donepezil, as required by its own Resident Change of Condition/Status policy. That policy, dated 4/11/25, states the facility must inform the resident, consult with the physician, and notify the resident’s family member or legal representative when there is a change requiring notification, including alterations in treatment such as new treatments or discontinuation of current treatments. The policy further notes that even when residents are cognitively competent, the physician must be contacted and the representative notified, particularly when a family has requested to be informed of significant health status changes. Resident #6, an older adult with dementia and frontal lobe/executive function deficits, was cognitively intact per a recent MDS (BIMS score 14/15) and dependent on staff for ADLs. A pharmacist note dated 10/30/25 recommended deprescribing donepezil due to lack of demonstrated efficacy and potential side effects; this recommendation was signed by the physician on 12/22/25, and the physician’s order shows the donepezil was discontinued on 1/7/26. Record review revealed no documentation that the facility communicated with the resident or the resident’s representative about either the pharmacist’s recommendation or the actual discontinuation of the medication. The resident’s representative reported she was not contacted prior to the discontinuation and only learned of it approximately two months later, which upset her. The DON confirmed in interview that the representative was not notified when the medication was discontinued, despite the facility’s policy and the resident’s capacity to understand medication changes.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure residents who were prescribed mechanically altered diets received food prepared according to their diet order of level six soft and bite-sized texture. Specifically, residents were served regular wheat rolls and green peas instead of the prescribed puree bread and cooked sliced carrots. This discrepancy was observed during a lunch meal service, where nine plates were assembled and delivered to residents with the incorrect food items, contrary to the diet spreadsheets provided by the consulting registered dietitian (CRD). During the lunch meal service, the dietary manager (DM) acknowledged that the facility had been serving regular wheat rolls and peas to residents on the level six soft and bite-sized diet. The DM admitted that the recipes and menu spreadsheets for the level six diet were available in the kitchen but were not referred to by the cook. The DM also expressed concerns about residents' acceptance of the commercially prepared puree bread mix and mentioned that further training was needed for the dietary staff on mechanically altered diet production. Additional staff interviews revealed that the dietary aide (DA) and executive chef (EC) were not fully trained on using the diet spreadsheets to prepare mechanically altered diets. The DA mentioned that the diet spreadsheets were no longer posted in the kitchen, leading her to rely on the cooks for diet modifications. The EC admitted to not having used the spreadsheets previously and acknowledged their importance in reducing choking and swallowing risks for residents. The registered dietitian (RD) confirmed that there had been no recent changes to many residents' diet orders, indicating a systemic issue in following prescribed diet modifications.
Sanitation and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the high-temperature dishwashing machine did not function at the proper temperatures, failing to reach the required 180 degrees Fahrenheit for sanitizing dishes. Observations showed that the dish machine's rinse temperature was consistently below the required 180 degrees Fahrenheit, and the facility did not have temperature indicator strips to verify the utensil surface temperature. The dish machine logs also failed to document corrective actions for the low temperatures, and staff were unaware of the proper operating instructions for the dish machine. Additionally, the chemical connected to the dish machine was a rinse aid, not a sanitizer, further compromising the sanitation process. During the lunch meal service, staff failed to perform proper hand hygiene while plating and serving resident meals. The cook was observed repeatedly touching her mask, hair, and other surfaces without washing her hands before handling clean dishes and serving food. This included touching her mask and hair multiple times, adjusting her name tag, and drinking from a cup without performing hand hygiene before returning to food preparation tasks. These actions were in direct violation of the Colorado Retail Food Regulations, which require food employees to clean their hands immediately before engaging in food preparation and after activities that contaminate the hands. Interviews with dietary staff revealed a lack of awareness and training regarding the proper procedures for monitoring dish machine temperatures and performing hand hygiene. The dietary manager admitted that staff did not know when to check the rinse temperature during the dishwashing cycle and were not aware of the dish machine's operating instructions. The consulting registered dietitian confirmed that the dish machine's booster heater was faulty, and the facility had to switch to a chemical sanitizer. Despite these issues, staff continued to use the dish machine without proper verification of sanitization levels, leading to potential contamination of dishes and utensils used for resident meals.
Failure to Properly Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to assess, accurately document, and provide treatment for a resident with pressure ulcers. Specifically, the facility did not consistently and accurately document the progress of the resident's pressure ulcers, failed to identify a reopened pressure wound on the resident's coccyx, and did not obtain appropriate physician's orders for wound care treatment for the reopened coccyx pressure ulcer. The resident, who had a history of dementia, chronic kidney disease, type II diabetes, and a previous stage 3 pressure ulcer, was observed multiple times sitting in a wheelchair without repositioning, which is critical for pressure ulcer prevention and management. Observations revealed that the resident had an open wound on the coccyx area, which caused significant pain during incontinence care. Despite this, the facility's documentation was inconsistent and inaccurate, with discrepancies in the recorded stages, locations, and measurements of the wounds. The facility's records also failed to show regular Braden Scale assessments after the initial one in January, and there was no documentation indicating that the physician was notified about the reopened wound. Interviews with staff revealed a lack of consistent communication and understanding regarding the resident's wound care. The wound care nurse provided conflicting information about the resident's wound status, and the nurse practitioner was not informed about the reopened wound. The director of nursing acknowledged that the physician should be contacted for new or reopened wounds, but this protocol was not followed. The facility's failure to properly assess, document, and treat the resident's pressure ulcers led to inadequate care and management of the resident's condition.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to ensure timely and adequate pain management for two residents, leading to significant discomfort and distress. Resident #32, who had dementia and a history of a right buttock stage 3 pressure injury, was observed in severe pain during incontinence care. Despite having physician orders for PRN Tramadol before wound care and brief changes, the resident did not receive any doses of PRN Tramadol from 5/1/24 through 5/14/24. Additionally, the required monitoring of the resident's pain every shift was inadequately documented, with no pain score or description of the pain provided. The care plan for Resident #32 also lacked documentation of individualized non-pharmacological interventions that were effective for her pain management. Resident #1, who had hemiplegia, hemiparesis, and other conditions, was also inadequately managed for pain. The resident's care plan did not identify the location of her pain or specify non-pharmacological interventions to help alleviate it. Despite being on a scheduled pain medication regimen and receiving as-needed morphine sulfate, the documentation did not include where the resident had pain or if non-pharmacological interventions were offered. Interviews with staff revealed inconsistencies in understanding and documenting the resident's pain, further complicating effective pain management. The facility's failure to document and manage pain effectively for these residents resulted in significant distress and discomfort. Observations and interviews indicated that the residents' pain was not adequately assessed or treated, and the care plans lacked necessary details to provide individualized care. This deficiency highlights a critical gap in the facility's pain management protocols and documentation practices.
Failure to Monitor and Document Psychotropic Medication Use and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not implementing appropriate non-pharmacological interventions for behaviors, not monitoring for side effects of psychotropic medications, and not consistently monitoring behaviors to justify the use of such medications. The resident, who was cognitively impaired and dependent on staff for various activities, was observed calling out for a nurse multiple times without receiving timely assistance. The care plans for the resident included the use of various psychotropic medications, but there was no documentation of monitoring for effectiveness, side effects, or the use of non-pharmacological interventions when the resident exhibited behaviors such as calling out. The facility's policy required licensed nurses and additional staff to monitor and document any targeted behaviors and include alternatives to psychopharmacological drug use in the care plan. However, the review of the resident's electronic medical record and medication administration record revealed a lack of documentation for monitoring the effectiveness and side effects of the medications. Additionally, there was no consistent documentation of the resident's behaviors or attempts at non-pharmacological interventions. Interviews with staff, including an LPN and the DON, confirmed that the facility did not consistently document behaviors, side effects, or non-pharmacological interventions. The LPN mentioned that non-pharmacological interventions such as companionship, social service intervention, and activities were known to help the resident, but these were not documented. The DON acknowledged the importance of documentation for determining the necessity and effectiveness of medications but admitted that the facility had failed to do so in this case.
Infection Control Deficiencies in Equipment Cleaning and Vaccination Clinic
Penalty
Summary
The facility failed to maintain an infection control and prevention program on the Parkview unit, specifically in the cleaning and disinfecting of mechanical lifts and vital signs equipment. Observations revealed that a certified nurse aide (CNA) did not disinfect a sit-to-stand mechanical lift after use, and another unidentified CNA did not disinfect vital signs equipment, including blood pressure cuffs, a pulse oximeter, and a thermometer, after use. Additionally, there were no cleaning wipes stored with the equipment, and the equipment was placed next to the nurses' station without being disinfected. The infection preventionist (IP) confirmed that CNAs were responsible for cleaning the equipment after each use with hydrogen peroxide wipes, which were readily available in the facility. During a vaccination clinic, a contract pharmacist (CP) was observed administering vaccinations without following proper hand hygiene protocols. The CP did not change gloves or perform hand hygiene between tasks, such as adjusting personal clothing, handling paper records, and administering vaccinations. The CP also placed band aids on potentially unclean surfaces like the sharps container and her watch. The IP confirmed that the CP should have performed hand hygiene before and after glove use and should not have touched unclean surfaces with gloved hands. Interviews with the IP revealed that the facility's cleaning policy for vital signs equipment depended on the presence of an outbreak and that hydrogen peroxide was used for disinfection. The IP also stated that the CP was from a contracted company and not an employee of the facility. The IP acknowledged that the CP's actions during the vaccination clinic did not adhere to proper infection control procedures, including the placement of band aids and the lack of hand hygiene between tasks.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| Riverbend Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 13 | 0 |
| Green House Homes At Mirasol, The | 3.2 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society -- Loveland Village | 3.7 mi | ★★★★★ | 15 | 0 |
| Good Samaritan Society -- Fort Collins Village | 5.1 mi | ★★★★★ | 12 | 0 |
| Lemay Avenue Health And Rehab Llc | 7.1 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.