The North Shore Estates LLC

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of potential verbal abuse and rough handling were immediately reported to the administration and State agency (SA) for 1 of 4 residents (R2) reviewed. A nursing assistant (NA) roughly handled R2 and made demeaning comments to him on 6/20/26 which were observed by another staff member; however, these allegations were not reported to the administrator until several days later; nor were they ever reported to the SA.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of physical and verbal abuse were thoroughly investigated and adequate follow up to prevent ongoing abuse for 1 of 4 residents (R2) reviewed. A nursing assistant (NA) had allegedly roughly handled R2 and made demeaning comments to him on 6/20/26 which were observed by another staff member; however, these allegations were not reported to the administrator until several days later nor thoroughly investigated to determine if abuse had occurred. Further, the delay in reporting allowed the alleged perpetrator (NA-E) to continue working unsupervised with other residents despite the allegations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure behaviors, including behaviors which were bothersome to other residents, were comprehensively assessed and interventions developed to ensure a consistent, therapeutic approach was done for 1 of 4 residents (R2) reviewed. R2 demonstrated physical and verbal behaviors with care and others which were not assessed to develop consistent interventions the staff could attempt or use while providing care.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the following infection prevention measures occurred: utilization of proper isolation signage, handwashing, appropriate utilization of personal protective equipment (PPE) by staff, proper handling of laundry to prevent bacteria growth, and proper hand sanitization during meal tray pass to residents in their rooms. These deficient practices had the potential to impact all residents who resided at the facility. Isolation Signage and PPE Usage R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact with diagnoses of hypertension, acute kidney failure, bipolar, and schizophrenia. R35 quarterly MDS dated [DATE], indicated R35 was cognitively intact with diagnoses of end stage renal disease with dialysis, diabetes and hypertension. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of abuse were reported within 24 hours to the State Agency (SA) for 1 of 1 resident (R11) reviewed for abuse.

Inspectors wroteBased on interview and document review the facility failed to ensure proper procedure, documentation and accounting procedures were followed for controlled substances reviewed for narcotic diversion.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure medications were properly stored and secured during medication pass. In addition, the facility failed to ensure floor stock melatonin, 3 milligrams (mg) administered to residents was pharmaceutical grade. These deficient practices had the potential to impact all residents on or who could access the second floor and/or receive melatonin 3 mg.

Inspectors wroteBased on observation and interview, the facility failed to serve food that remained at palatable temperatures through delivery of the food to the residents for 2 of 2 residents (R3, R61) reviewed for food quality concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was properly labeled and stored to prevent food-borne illness. In addition, the facility failed to ensure kitchen cleanliness was maintained in areas where food was prepared. These deficient practices had to potential to affect anyone who ate food prepared by the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents without an assessment and order to self-administer medications (SAM) were not left with prescription medications to take on their own for 1 of 1 resident (R61) reviewed for self-administration of medication.

Inspectors wroteBased on observation, interviews and document review the facility failed to ensure diabetic snacks were provided to 2 of 2 residents (R7, R57) reviewed for food service.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure provider-ordered interventions were in place for safe swallowing for 1 of 3 residents (R61) reviewed for accident hazards.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure ice packs for personal use were not stored with resident food. This had the potential to affect residents who stored or consumed food from the unit freezers.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the care plan after discontinuation of self-administered medication for 1 of 1 residents (R50) reviewed for care planning.

Inspectors wroteBased on interview and document review, the facility failed to provide ongoing, comprehensive discharge (DC) planning to a lower level-of-care for 1 of 2 residents (R49) reviewed for discharge planning.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure oral cares were completed for 1 of 3 residents (R18) reviewed for personal cares.

Inspectors wroteBased on document review and interview, the facility failed to identify diagnoses or indications for use of medications for 1 of 5 residents (R1) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to complete orthostatic blood pressure monitoring for an antipsychotic medication for 1 of 5 residents (R49), reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure kitchen equipment was kept in a clean and sanitary manner. This had the potential to affect all 54 residents, staff, and visitors who consumed food prepared in and/or served from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that temperature-controlled medications were properly stored for 3 of 8 residents (R3, R9, R33) and any resident needing medications from the pharmacy-provided emergency kit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper personal protective equipment use and hand sanitization occurred during food preparation. This had the ability to affect all residents, staff, and visitors who consumed food in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure medications were not left unattended at bedside for 1 of 1 resident (R16) reviewed for self-administration of medication.

Inspectors wroteBased on interview and document review, the facility failed to accurately code Minimum Data Set (MDS) for 1 of 4 residents (R25) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure provider orders for a c-pap (continuous positive airway pressure) [a machine that provides breathing support for individuals that experience pauses in breathing when they sleep] were followed for 1 of 1 resident (R206) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure post-dialysis access site monitoring was consistently completed to provide continuity of care and reduce the risk of complication (i.e., bleeding, clotting) for 1 of 1 residents (R33) reviewed for dialysis care.

Inspectors wroteBased on interview and document review, the facility failed to follow the most recent Centers for Disease Control (CDC) standards for offering and educating on pneumococcal vaccinations for 2 of 5 residents (R11, R29) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster.