North Shore Health: Edema Monitoring Failures - MN
The resident, identified in inspection records only as R6, was admitted with a documented history of chronic lower extremity edema and stage-four chronic kidney disease, a condition involving significant, permanent loss of kidney function. At the time of the clinical admission assessment, nurses noted his left and right lower extremities were extremely puffy, with mild non-pitting edema in the calves, ankles, and the tops of both feet.
That was the last time anyone systematically documented what was happening to his legs.
His care plan, dated April 19, contained no focus statement for edema management. A provider order from May 7 directed staff to weigh him every Thursday morning, but said nothing about monitoring for edema. By May 19, a monthly rounding note described two-plus pitting edema reaching his knees, noting it as stable. No one appears to have asked what it was stable compared to, or whether that assessment was based on any documented baseline.
On May 25, a nurse finally contacted R6's provider and notified the nurse manager. The reason: an 18.1-pound weight gain since admission.
When inspectors observed R6 the following evening, both of his lower extremities were visibly, severely swollen. R6 told them that is how they have been, and that he used to have compression socks in the past, but not here.
By the morning of May 27, the situation had worsened further. RN-A, the nurse who spoke with inspectors that afternoon, said she had just noticed the weight gain the previous weekend and had notified the provider and nurse manager. She explained that edema monitoring had previously been on the treatment administration record, but the provider discontinued it and started a nebulizer instead. On the day inspectors interviewed her, R6 had diminished lung sounds. Both lower legs had progressed to three-plus pitting edema. She said she had been waiting to hear whether new orders were coming and confirmed they had received a Lasix prescription, a diuretic used to reduce fluid retention. She said she felt his legs had been getting bigger, and that the risks going forward were skin breakdown and his legs beginning to weep fluid through the skin.
The director of nursing told inspectors she would have expected nurses to assess the edema and listen to his lungs on an ongoing basis, and would have expected that monitoring to be documented and reflected in the care plan. She added that even after the provider discontinued the edema monitoring order, it remained within a nurse's professional scope to monitor edema independently.
That statement is the quiet center of what went wrong here. A provider removed a monitoring order. Nurses did not replace it with their own clinical judgment. A man with failing kidneys sat in a facility for weeks as his legs filled with fluid, and the care plan said nothing about it.
R6's condition at the end of the inspection, diminished lung sounds and three-plus pitting edema to both lower legs, suggests the fluid had moved beyond his extremities. Whether the Lasix prescription came in time to prevent further harm, inspectors did not say.
He told them he used to have tight socks for his legs. Not here.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Shore Health from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
NORTH SHORE HEALTH in GRAND MARAIS, MN was cited for violations during a health inspection on May 27, 2026.
That was the last time anyone systematically documented what was happening to his legs.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.