North Shore Health & Rehab Facility

In the surveyor’s words

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

• Actual harm, isolatedF697Jul 9, 2026

  Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#92 and #56) of two residents reviewed for pain management out of 54 sample residents. Resident #92 was admitted to the facility on [DATE]. Resident #92 had a history of osteoarthritis and pain. On 7/6/26, the facility failed to ensure the resident's oxycodone medication was administered timely. Resident #92's medication was not administered until five hours after it was scheduled, which resulted in Resident #92 experiencing increased pain.Resident #56 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF558Jul 9, 2026

  Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for eight (#50, #7, #58, #2, #12, #56, #110 and #21) of 12 residents reviewed for accommodation of needs out of 54 sample residents. Specifically, the facility failed to ensure Resident #50, Resident #7, Resident #58, Resident #2, Resident #12, Resident #56, Resident #110 and Resident #21, who relied on bedside halo bars and transfer poles for mobility, had appropriate accommodations after the facility removed all bedside halo bars and transfer poles from resident rooms. Findings include: I. […]

• No harm, potential for more than minimal, patternF565Jul 9, 2026

  Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances.Specifically, the facility failed to effectively address, resolve and document resolutions to residents' concerns regarding long call wait times in a timely manner.Findings include: I. Facility policy and procedure The Grievance policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 11:06 a.m. It revealed in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2026

  Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Ensure food items were properly covered, labeled and dated;-Ensure food was thawed according to safe food handling practices; and,-Ensure the dishwasher washed his hands and changed single-use glove use appropriately during meal service.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 7/14/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. […]

• No harm, potential for more than minimal, patternF805May 16, 2024

  Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet order of level six soft and bite-sized texture as indicated on their meal tray cards. Findings include: I. Professional reference The International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), was retrieved on 5/21/24, from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, Level six soft and bite-sized, for safety avoid these food textures that pose a… […]