Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 The North Shore Estates Llc during CMS and state inspections, most recent first.
The facility failed to follow infection prevention practices for residents on isolation precautions, including incorrect isolation signage, inconsistent hand hygiene, and improper PPE use. Staff entered resident rooms without sanitizing hands or wearing the PPE indicated, and isolation carts were not consistently stocked with hand sanitizer. Laundry was also left in a washer overnight, and during meal tray pass a NA wore the same gloves while handling multiple trays and food items without hand hygiene after glove removal.
Failure to Report Alleged Misappropriation Within Required Timeframe: A resident with a femur fracture, AFib, insomnia, anxiety, and chronic pain was cognitively intact and receiving scheduled and PRN pain meds. The facility learned of an allegation that pain meds were signed out twice overnight and that the resident slept through the night without pain medication, completed an investigation, but did not report the allegation to the SA within the required 24 hours.
The facility failed to properly document and account for controlled substances during a narcotic diversion concern. A TMA reported a resident said they had not taken narcotics despite the narcotic book showing oxycodone signed out, and multiple controlled-drug records showed missing second signatures, missing times, undocumented destruction, a pill missing from a card, and a medication signed out after it was documented as given in the EMR. The DON and consultant pharmacist also described gaps in assessment, documentation, and investigation reporting.
An RN left an unlocked med cart unattended during med pass with inhalers, eye drops, and cups of pills on top of the cart, and later left it unattended again with medications still exposed. Staff confirmed the cart should have been locked when not attended. The facility also stored floor stock melatonin 3 mg on multiple carts even though the bottles had no expiration date, and the CP stated products without an expiration date are not pharmaceutical grade medications.
Food Served at Inadequate Temperatures: Two residents reported that meals delivered to their rooms were often not hot, and one said dining room meals were only marginally warmer. Surveyors observed hot food plated on heated plates and covered, then loaded into non-insulated speed carts; by the time the cart reached the end of the hall, the chicken and green beans were barely warm, and the culinary director said the food was at the low end of his temperature expectations.
Failure to Offer Substantial Evening Snacks: The facility did not ensure residents were offered a substantial evening snack when there was more than a 14-hour gap between dinner and breakfast. The DM stated she was unaware of the gap and acknowledged there was no process to ensure an evening snack was routinely provided. Records also showed concerns about limited nighttime snacks on the second floor, with some residents taking multiple items and diabetic snacks being hoarded.
Improper Food Labeling and Unsanitary Kitchen Conditions: Opened food items in the kitchen were not consistently labeled with opened-on dates or properly secured, including coleslaw, parmesan cheese, diced onions, cake mix, and another container of prepared coleslaw. In the meal service area, surveyors observed soiled floors, dried splatter on the steam table glass, exposed damage on a pillar beside the steam table, a cleaning pad stored above a food prep counter, peeling ceiling tile material, and dust and hair on an air-handling unit. The DM confirmed the labeling problems and stated the steam table glass did not appear to have been cleaned after the last meal service.
A resident with intact cognition and diagnoses including GERD, DM, anemia, CHF, protein-calorie malnutrition, and CKD stage 3 was observed in bed eating breakfast with a cup of pills on her tray table, stating the pills were hers and that she had to take them with orange juice. The resident had no SAM assessment or provider order, and her care plan did not include SAM focus statements or interventions. Staff later confirmed she was not approved for self-administration, while the DON stated only residents with assessed and doctor-ordered SAM should take medications on their own.
A facility failed to provide ordered diabetic bedtime snacks for two residents with diabetes. One resident had an order for a bedtime deli sandwich, and both residents had care plans calling for diabetic snacks, but staff reported sandwiches and other diabetic-appropriate items were not consistently available on the units. Interviews and observations showed the refrigerators often lacked meat and cheese, there was no evening snack cart, and available snacks were often items like cookies, cake, pudding, and Jello instead of ordered diabetic snacks.
Failure to Follow Ordered Swallowing and Feeding Interventions: A resident with GERD, CHF, CKD, anemia, DM, and protein-calorie malnutrition had provider orders for thin liquids, small bites and sips, alternating bites and sips, oral care after intake, and upright positioning during and after meals, but the care plan did not include swallowing-focused instructions. Surveyors observed the resident eating in her room without staff present, including tough toast and a meal served while she was positioned at about 20 degrees in bed. The resident said staff dropped off the tray and returned later, and an NA said there were no special eating instructions on the care guide. The RN and DON confirmed the orders should be followed and identified choking and aspiration as risks.
The facility failed to prevent the storage of personal use ice packs with resident food in unit freezers, posing a potential infection control risk. An administrator found ice packs labeled for body use in a freezer with resident-labeled food. The culinary director and an LPN confirmed that non-food items should not be stored with food, and the DON acknowledged the infection control concern. The facility's policy did not address ice pack storage.
A facility failed to update a resident's care plan after discontinuing a self-administered medication. The resident had a complex medical history, and the care plan, last reviewed in early January, still included instructions for self-administering tenapanor, despite the medication being discontinued in late October. Interviews with the DON and an LPN confirmed that care plans should be updated with treatment changes, but this was not done, resulting in a deficiency.
A resident in a nursing home expressed a desire to move to an Assisted Living Facility (ALF), but the facility failed to provide comprehensive discharge planning. Despite initial plans and assessments, the social services department did not follow through with necessary referrals or actions. Interviews confirmed that the resident's discharge wishes were not adequately addressed, and the facility's discharge planning policy was not effectively implemented.
A resident with multiple sclerosis, who required assistance with personal hygiene, was not consistently offered oral care as per their care plan. Despite the facility's policy to provide oral care, observations and interviews revealed that nursing assistants did not offer or perform oral care during morning routines, and the resident reported being offered the opportunity to brush his teeth only twice in a week.
A resident was prescribed multiple medications without documented indications for use, despite having several diagnoses. Facility staff confirmed the expectation for each medication to have a diagnosis or indication, and the facility's policy required clarification if orders seemed unrelated to the resident's conditions.
A facility failed to conduct required orthostatic blood pressure monitoring for a resident on Quetiapine, an antipsychotic medication. Despite the facility's policy and the resident's diagnoses of anxiety disorder, manic depression, schizophrenia, and PTSD, no orthostatic blood pressures were documented from January to March. Interviews with LPNs and the DON confirmed the oversight, highlighting the importance of monitoring due to potential blood pressure drops caused by the medication.
Infection Control Failures in Isolation, Laundry, and Meal Tray Handling
Penalty
Summary
The facility failed to ensure infection prevention and control measures were followed for residents on isolation precautions, including proper signage, hand hygiene, and use of PPE. R9, R35, and R56 were identified in the facility’s precaution list as being on contact and droplet precautions or enhanced barrier precautions, with R35 also listed for dialysis and wound-related precautions. However, during observations, the doors for R9, R35, and R56 displayed only droplet precaution signs at various times, and staff entered rooms without sanitizing hands or applying the PPE indicated by the precautions. One nursing assistant entered R9’s room without sanitizing hands or applying gown, gloves, or a mask, and a registered nurse entered R9 and R35’s rooms without hand hygiene or PPE. The DON later stated the facility’s reference tool had been incorrect and that contact precautions and masks should have been used for human metapneumovirus, and that the droplet-only signage on those rooms was not adequate. Hand hygiene supplies were also inconsistent in the isolation area. During observation of the low 200 hallway, there were no wall-mounted hand sanitizer dispensers, and only one of nine isolation carts had a small bottle of hand sanitizer. The DON later observed the carts and confirmed they should all be stocked with hand sanitizer. Staff interviews showed that some staff relied on the door signage and shift report to determine PPE use, while others acknowledged they should have worn masks and additional PPE for droplet or contact precautions. The facility’s infection prevention and control program stated that appropriate isolation precautions should be implemented and CDC guidelines followed. Laundry handling and meal tray delivery practices also did not follow infection prevention expectations. A laundry aide placed a load of laundry in a washing machine at the end of a shift and left it overnight, and the housekeeper supervisor stated staff had been told it was acceptable to start laundry at the end of the day and process it in the morning. The DON stated laundry should not be left in washing machines overnight because it gave mold and/or bacteria an opportunity to grow. During meal tray pass, a nursing assistant wore the same gloves while delivering trays to multiple residents, handling used trays, moving the cart, and touching food items, and then removed the gloves without performing hand hygiene. The DON verified staff should perform hand hygiene before and after delivering each resident tray and should wear gloves if touching food.
Failure to Report Alleged Misappropriation Within Required Timeframe
Penalty
Summary
The facility failed to ensure an allegation of abuse/misappropriation of resident property was reported to the State Agency within 24 hours. The concern involved a resident whose five-day MDS identified diagnoses including displaced intertrochanteric fracture of the left femur with routine healing, paroxysmal atrial fibrillation, insomnia, anxiety, and chronic pain; the resident was also documented as cognitively intact and receiving scheduled and as-needed pain medications for frequent pain. A complaint later submitted to the State Agency stated the resident reported sleeping through the night without any pain medication, and the reporter noted pain medications had been signed out twice overnight for the resident. The facility was made aware of the allegation on 10/20/25 and completed an investigation at that time, but did not report the allegation to the State Agency. During interviews, the NP recalled the reporter raising concerns and giving the reporter the State Agency phone number, and also recalled discussing the concern with the nurse manager and that the facility completed an investigation. The RN could not recall recent concerns related to a possible narcotics problem. The administrator verified the facility completed an investigation related to potential narcotic diversion in October 2025 and verified the allegation was not reported to the State Agency. The facility policy stated that suspected neglect, exploitation, or misappropriation of resident property not resulting in serious bodily injury must be reported within 24 hours.
Controlled Substance Documentation and Diversion Investigation Lapses
Penalty
Summary
The facility failed to ensure proper procedure, documentation, and accounting for controlled substances reviewed for possible narcotic diversion. A TMA reported that a resident said they had not taken any narcotics over the weekend, yet the narcotic book showed oxycodone had been signed out to that resident. The TMA reported the concern to the facility and to the resident’s provider, and the NP stated she was told about the narcotic concern and discussed it with the facility. The administrator stated the alleged perpetrator did not show signs of impairment and that the facility investigated the concern, but the allegation was not reported to the state agency. Review of the narcotic books showed multiple controlled substance entries involving AP-B with documentation problems. These included hydrocodone/APAP and hydrocodone entries marked as dropped on the floor without a second signature, oxycodone and lorazepam entries documented as destroyed with second staff signatures, and one lorazepam entry with no time documented. Progress notes for a resident did not identify why lorazepam was destroyed on three dates. One oxycodone entry noted pill number 3 missing from the card, and staff later stated the missing pill was found in the suboxone box. Another oxycodone entry showed morphine was given in the EMR before it was signed out in the narcotic book, and a sticky note asked AP-B to sign for it. The consultant pharmacist stated they had not been made aware of the facility’s investigation and should have been involved. The DON stated a nurse should assess a resident before a TMA gives an as-needed narcotic and that there should have been a progress note documenting the assessment. Facility policy required controlled medication doses that were refused or not given for any reason to be destroyed in the presence of two licensed nurses and documented on the accountability record, and required discrepancies, loss, or diversion to be reported immediately with investigation and review of controlled drug accountability procedures.
Unsecured medication carts and non-pharmaceutical grade melatonin stored on carts
Penalty
Summary
Medication storage and security were not maintained during medication pass. During observation, an RN stepped away from an unlocked medication cart in the hallway and entered resident rooms while inhalers, eye drops, and two medication cups containing multiple pills remained on top of the cart. The cart was left unattended and unlocked again moments later, with the second large drawer partially open and the same medication cups, inhaler, and a card of pills still on the cart surface. The RN acknowledged leaving the cart unattended with medications exposed and stated they knew the cart was supposed to be locked when walking away, but did not always do so when briefly entering a room. The DON stated medication carts should never be left unlocked and unattended and medications should never be left on the surface of carts unattended. The facility also stored floor stock melatonin 3 mg that did not have an expiration date. On two medication carts, sealed and open bottles of Basic Brands melatonin 3 mg were found with only a manufacture date of 6/2024 and no expiration date. Staff confirmed the bottles lacked expiration dates, and the consultant pharmacist stated pharmaceutical grade medications and supplements must have an expiration date and that products without one are treated as food products or supplements, not medications. The administrator reported multiple quantities of this melatonin were present in medication carts on different units, and a list of residents who received the floor stock melatonin was requested but not received.
Food Served at Inadequate Temperatures
Penalty
Summary
Food and drink were not maintained at palatable, appetizing temperatures through delivery to residents for 2 of 2 residents reviewed for food quality concerns. Resident R3 had intact cognition, was independent with eating, and had diagnoses including MRSA infection, acquired absence of the right leg below the knee, infection and inflammatory reaction due to an internal left knee prosthesis, and rheumatoid arthritis. R3’s care plan addressed increased nutritional needs related to wound status and healing, and she reported that food was not hot when it reached her room. She stated dietary had told her food would be warmer if she ate in the dining room, but when she tried that it was only marginally warmer and she did not like going there because it was a hassle. Resident R61 had intact cognition, was independent with eating, and had diagnoses including GERD, DM, anemia, CHF, protein-calorie malnutrition, and CKD stage 3. R61 stated she usually ate in her room and that the food was often not hot by the time it got to her. During observation, hot food was plated, placed on heated plates with insulated covers, then loaded into non-insulated speed carts and sent down hallways in sequence; by the time the cart reached the far end of the first-floor east hall, the surveyor’s test tray chicken and green beans were barely warm, and the regional culinary director stated the chicken was at the low end of his expectations for temperature. Staff and management also acknowledged that residents in their rooms often received food that was cold or not hot by the time it reached the end of the hall.
Failure to Offer Substantial Evening Snacks
Penalty
Summary
The facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. A facility-submitted document dated 11/1/25 showed breakfast was scheduled from 7:45 a.m. to 8:15 a.m., lunch from 11:45 a.m. to 12:15 p.m., and dinner from 4:45 p.m. to 5:15 p.m., creating more than a 14-hour span between the evening meal and the next day’s breakfast. The facility policy on Frequency of Meals stated there would not be more than a 14-hour span between the evening meal and breakfast and that nourishing snacks would be available, including evening snacks offered routinely to all residents. During interview, the dietary manager stated she was not aware there were more than 14 hours between meals and said the facility normally sent snacks upstairs to be stocked on each floor around 3 p.m. She also stated that starting that day they would be sending up diabetic snacks at around 6 p.m. The dietary manager identified the facility did not have a process for ensuring residents were offered a substantial evening snack. An email from the dietary manager to the administrator noted concerns that the second floor did not have much for snacks at night and that some individuals were getting multiple items and leaving nothing for the rest. Food committee minutes also documented concerns about additional snacks being needed because they were being eaten quickly and that diabetic snacks were being hoarded.
Improper Food Labeling and Unsanitary Kitchen Conditions
Penalty
Summary
Food was improperly labeled and stored in the kitchen, including a commercially prepared container of coleslaw dated as opened on 1/21/26, a bag of shredded parmesan cheese that was open but not labeled with an opened-on date, a commercially prepared bag of diced onions that was opened, folded, and saran wrapped without an opened-on date, and a bag of cake mix that had been opened and not secured or labeled. In the cook's refrigerator, another container of prepared coleslaw was also open without a date. During the observation, the dietary aide confirmed the labeling issues, and the dietary manager stated the items should have been labeled when opened and that the unlabeled items would be thrown out. The dietary manager also stated the risk of keeping food too long would be that it could make someone sick. Kitchen cleanliness was also not maintained in the area where food was prepared and served. In the steam table and tray line room, the floor had visible soil and foot traffic with shoe prints and dried brown and black spots. The inside of the steam table glass nearest the hot food was covered with dried splatters and drips, and the pillar beside the steam table was missing corner guards with exposed dried glue and small pieces of missing sheetrock, along with brownish-black staining from about hip to shoulder height. A steel cleaning pad was left on top of upper cabinets above a food preparation counter, two ceiling tiles above the beverage staging area had peeling plastic, and an air-handling system near the beverage area had a collection of hair and dust hanging from the bottom. The administrator stated maintenance looked at the kitchen at least weekly and as needed, and the dietary manager stated she would not expect to have dust bunnies and confirmed the steam table glass did not appear to have been cleaned after the last meal service.
Resident Left With Medications Without SAM Assessment or Order
Penalty
Summary
The facility failed to ensure that a resident without an assessment and order for self-administration of medications was not left with prescription medications to take on her own. The resident had a quarterly MDS showing intact cognition and diagnoses including GERD, DM, anemia, CHF, protein-calorie malnutrition, and CKD stage 3. Her care plan did not contain a focus statement or interventions for self-administration of medications, and her provider orders did not include an order for self-administration of any medication. During an observation, the resident was in bed eating breakfast with a cup of pills on her tray table, and she stated the pills were hers and that she had to take them with her orange juice. No facility staff were present in the room at that time. A NA stated there were no special instructions for eating, and an RN later verified in the medical record that the resident was not approved for self-administration of medications. The RN stated she would expect an assessment and order for self-administration, and the DON stated only residents with assessed and doctor-ordered self-administration should be taking their medications on their own.
Diabetic bedtime snacks not provided as ordered
Penalty
Summary
The facility failed to ensure diabetic bedtime snacks were provided as ordered for two residents with diabetes, both of whom were cognitively intact and had care plans that included encouragement of a diabetic bedtime snack. One resident had orders for a bedtime deli sandwich, a consistent carbohydrate diet, blood sugar checks before meals and at bedtime, and medications including Lantus, metformin, and Ozempic. The other resident had orders for a consistent carbohydrate diet, blood sugar checks before meals and at bedtime, and insulin therapy with Humalog and Lantus. A review of the evening meal ticket for one resident did not include any information about a bedtime snack. During interviews and unit observations, staff reported that sandwiches were not consistently available in the refrigerators, that the refrigerators often lacked meat and cheese, and that after 7:00 p.m. there was no one in the kitchen to make a sandwich. Staff also stated that diabetic snacks were supposed to include items such as fruit, vegetables, or a meat and cheese sandwich, but these items were not consistently present. The dietary manager verified that there were no sandwiches in the refrigerators and that sugar-free Jello or puddings were not available for diabetic residents. Food council notes reflected resident concerns that there was not much available for snacks at night and that there were no dietary staff to pass an evening snack. Residents and staff further reported that the available snacks on the units were often items such as chips, cookies, cake, pudding, Jello, and peanut butter crackers, while diabetic-appropriate options were not consistently stocked. The DON stated that if a diabetic snack was ordered, the resident should receive it as ordered and that a bedtime snack was important for residents with diabetes to help keep blood sugars stable.
Failure to Follow Ordered Swallowing and Feeding Interventions
Penalty
Summary
The facility failed to ensure provider-ordered swallowing and feeding interventions were in place for one resident with intact cognition and diagnoses including GERD, DM, anemia, CHF, protein-calorie malnutrition, and CKD stage 3. The resident’s quarterly MDS identified no chewing or swallowing difficulty and no unplanned weight loss, and the care plan addressed potential altered nutrition related to diet texture or consistency but did not include a focus on swallowing difficulty or instructions for eating and drinking. The provider orders included regular thin liquids, alternating sips and bites, small single sips and bites, oral care after all oral intake, upright positioning for 30 to 60 minutes after intake, effort swallow, and medications as tolerated; later orders also included upright 90 degrees during oral intake and a regular diet with regular texture and thin liquids. Observations showed the resident eating in her room without staff present, including a meal tray with garlic toast that she said was too tough to chew, a salad with dressing and chicken breast with no sauce or gravy, and breakfast while positioned in bed at about 20 degrees with a tray over the bed. The resident stated staff brought the tray and returned later to get it, and no one checked back with her. She also stated she had to ask for more toast because what she received was too hard to cut. A hospital discharge summary identified an admission diagnosis of aspiration pneumonia of both lower lobes. An NA stated there were no special instructions for eating on the care guide, and the RN and DON confirmed the feeding orders should be followed and identified choking and aspiration as risks.
Inappropriate Storage of Ice Packs with Resident Food
Penalty
Summary
The facility failed to ensure that ice packs intended for personal use were not stored with resident food in the unit freezers, which could potentially affect residents who stored or consumed food from these freezers. During an inspection, the administrator found a large blue ice pack labeled for body use and two other reusable ice packs with a resident's name in the freezer containing resident-labeled food. The administrator confirmed that ice packs for body use should not be stored with food. The culinary director stated that the dietary department was responsible for the unit refrigerator/freezers and expected staff to notify her and the nurse if non-food items were found in the freezers. An LPN stated that ice packs should not be reusable or stored in the freezers, and the director of nursing confirmed that storing non-food items with resident food was an infection control concern. The facility's policy on refrigerators and freezers, dated December 2014, did not address the storage of ice packs in unit freezers.
Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to review and revise the care plan for a resident after the discontinuation of self-administered medication. The resident, identified as R50, had a comprehensive medical history including conditions such as amputation of the lower right leg, congestive heart failure, obesity, gastritis, hypo-osmality, hyponatremia, type 2 diabetes, ascites, hyperparathyroidism of renal origin, and end-stage renal disease. The care plan, last reviewed on January 3, 2025, included a focus on the resident's self-administration of tenapanor, a medication to lower phosphorus levels in the blood. However, the medication order was discontinued on October 31, 2024, but the care plan was not updated to reflect this change. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the facility's expectation was for care plans to be updated when there were changes in treatments. The DON and LPN identified that nurse managers were responsible for updating care plans for residents on their unit. The facility's policy on care planning, last revised in November 2024, stated that care plans should be modified and updated as the condition and care needs of the resident change. Despite these expectations and policies, the care plan for the resident was not revised following the discontinuation of the medication, leading to a deficiency in care planning.
Failure in Comprehensive Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide ongoing, comprehensive discharge planning for a resident, identified as R49, who was reviewed for discharge planning. R49 was admitted to the nursing home from an acute hospital and initially had an active discharge plan to return to the community. However, subsequent assessments indicated that no active discharge plan was in place, and no referrals to local agencies were made, as they were reportedly not wanted. Despite R49's expressed desire to move to an Assisted Living Facility (ALF) and the completion of a necessary assessment for ALF qualification, the facility did not follow through with the discharge planning process. R49's progress notes revealed that the resident expressed interest in moving to an ALF or a group home, but the facility's social services department did not follow up on these requests. Although a care conference was held, and contact information for assisted living locators was provided, there was no documentation of follow-up actions to assist with ALF referrals or discharge planning. Interviews with the resident and facility staff confirmed that the resident's discharge wishes were not adequately addressed, and the social services department did not complete the necessary referrals or follow-up actions. The facility's discharge planning policy indicated that discharge planning should start at admission, with efforts made to meet the resident's goals. However, the social services designee and regional licensed social worker acknowledged that the necessary follow-up actions were not taken, and the resident's discharge planning process was not completed. The administrator confirmed that the social services department was responsible for assisting residents with discharge planning, but the process was not effectively carried out for R49.
Failure to Provide Consistent Oral Care for Resident
Penalty
Summary
The facility failed to ensure that oral care was completed for a resident diagnosed with multiple sclerosis, who was cognitively intact and required assistance with personal hygiene. The resident's care plan specified that staff should provide assistance with oral care in the morning, at bedtime, and as needed. However, during an observation, nursing assistants assisted the resident with morning care but did not offer or perform oral care, such as brushing teeth. Interviews with the nursing assistants and the resident confirmed that oral care was not consistently offered, with the resident stating he was only offered the opportunity to brush his teeth twice in a week. The facility's policy on Activities of Daily Living required that residents be given appropriate treatment and services to maintain or improve their ability to carry out daily activities, including oral care. Despite this policy, the nursing assistants and LPNs interviewed acknowledged that oral care should be part of morning care routines, but it was not consistently provided. The director of nursing also confirmed that oral care should be offered to prevent dental problems and infections, highlighting a gap between the facility's policy and the actual care provided to the resident.
Failure to Document Indications for Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary medications, as evidenced by the lack of diagnoses or indications for use for medications prescribed to one resident. This resident, who had intact cognition and multiple diagnoses including schizoaffective disorder, type 2 diabetes, osteoarthritis, chronic bronchitis, rash, polyneuropathy, and chronic pain syndrome, was prescribed several medications and supplements without documented indications for their use. The medications included benzonatate, cadexomer iodine, carbidopa-levodopa, clobetasol propionate, gabapentin, guaifenesin ER, interdry, menthol-methyl salicylate, miconazole nitrate, an unnamed external lotion, and zinc. The medication administration record also lacked indications for these medications. Interviews with facility staff, including registered nurses, the director of nursing, and the administrator, confirmed that the expectation was for each medication to have a diagnosis or indication for use. The staff acknowledged that medications should have a diagnosis or indication as part of the order, and if missing, clarification should be sought from the provider. The facility's policy on medication administration indicated that if a medication order seemed unrelated to the resident's current diagnoses or conditions, the nurse should seek clarification prior to administration. Despite this policy, the deficiency was identified during the survey.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete orthostatic blood pressure monitoring for a resident receiving antipsychotic medication, specifically Quetiapine, which was prescribed at a dosage of 400mg to be taken at bedtime. The resident, who had intact cognition, was diagnosed with anxiety disorder, manic depression, schizophrenia, and post-traumatic stress disorder. Despite the facility's policy requiring monthly orthostatic blood pressure checks for residents on psychotropic medications, the treatment administration record and vital signs records from January 1 to March 1 lacked documentation of any orthostatic blood pressures being taken for this resident. Interviews with facility staff, including two LPNs and the Director of Nursing, confirmed that orthostatic blood pressures should have been monitored monthly and documented in the medical record. The LPNs acknowledged the oversight and emphasized the importance of this monitoring due to the potential for antipsychotic medications to cause sudden drops in blood pressure, which could harm the resident. The facility's policy on psychotropic medication use, last reviewed in January, also stipulated the necessity of monthly orthostatic blood pressure checks unless otherwise directed by a provider.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 117 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dove Healthcare - Superior | 2.9 mi | ★★★★★ | 3 | 0 |
| Viewcrest Health Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Twin Ports Health Services | 4.7 mi | ★★★★★ | 4 | 0 |
| Villa Marina Health And Rehabilitation Center | 5.6 mi | ★★★★★ | 9 | 0 |
| Bayshore Residence And Rehabilitation Center | 5.9 mi | ★★★★★ | 2 | 0 |
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