North Shore Health

In the surveyor’s words

From the most serious findings on record at North Shore Health, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 14, 2021

  Based on interview and document review, the facility failed to ensure a mechanical lift sling was properly placed for 1 of 2 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R1, when she fell from a mechanical lift, resulting in a laceration to her head that required sutures, and rib fracture. R1 died the next morning. The deficient practice was identified as an IJ situation, however, the provider had already implemented corrective action prior to the investigation so the deficiency is issued as past noncompliance. The IJ began on [DATE], when the facility failed to correctly connect the mechanical lift sling loops to the mechanical lift. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  Based on observation, interview, and document review, the facility failed to ensure the facility's dishwasher temperatures were reaching the minimum temperature for the wash and rinse cycles. This deficient practice had the potential to affect all 27 residents who received meals from the facility's kitchen. Findings include: During an initial tour of the kitchen with cook (C)-A on 8/14/23 at 6:35 p.m., C-A stated the dishes were all washed for the day. C-A said the dishwasher was hot water sanitization. The dishwasher temperatures were filled in sporadically for August. The dishwasher had a label on the side of the machine [NAME] with wash temperature of 160 degrees Fahrenheit (F) and rinse temperature of 180 degrees F. […]

• No harm, potential for more than minimal, widespreadF885Jul 14, 2022

  Based on interview and document review, the facility failed to notify residents, representatives and families of confirmed cases of Coronavirus Disease 2019 (COVID-19), when one employee tested positive for COVID-19, per current federal guidelines. In addition, the facility failed to provide cumulative updates weekly to residents, their representatives and families of any subsequent positive cases or respiratory illnesses. This deficient practice had the potential to affect all 31 residents, families and representatives at the facility. […]

• No harm, potential for more than minimal, widespreadF730May 28, 2021

  Based on interview and document review, the facility failed to complete annual performance evaluations for 3 of 5 nursing assistants (NA-C, NA-F, NA-G )who had been employed by the facility for over one year. This had the potential to affect all 37 residents who resided in the facility. Findings include: An undated employee list provided by the facility indicated the following: NA-C's hire date was 2/17/20. No annual performance evaluation had been completed in 2020. NA-F's hire date was 8/25/17. No annual performance evaluation had been completed in 2020. NA-G's hire date was 3/31/20. No annual performance evaluation had been completed in 2020. On 5/27/21, at 3:37 p.m. the director of nursing (DON) was interviewed. […]

• No harm, potential for more than minimal, patternF628Jul 31, 2025

  Based on interview and document review, the facility failed to provide a written bed hold for 2 of 2 residents (R5, R30) reviewed for hospitalization. In addition, the facility failed to notify the Ombudsman of the transfers to the hospital.Findings include: R30 R30's quarterly Minimum Data Set (MDS) identified resident as cognitively intact with diagnoses of hemiplegia (paralysis affecting one side of the body) following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), depression, anxiety, anemia, dysuria (pain or discomfort during urination), obstructive and reflux uropathy (condition affecting the urinary tract and the flow of urine), and a personal history of prostate cancer. […]