Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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 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.
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.
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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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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 | — | 2 | 0 |
| Viewcrest Health Center | 4.6 mi | — | 0 | 0 |
| Twin Ports Health Services | 4.7 mi | — | 4 | 0 |
| Villa Marina Health And Rehab Ctr | 5.6 mi | — | 9 | 0 |
| Bayshore Residence And Rehabilitation Center | 5.9 mi | — | 2 | 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 August 2026) and official state health department websites.