North Shore Health: Care Plan Failures for Chronic Conditions - MN
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on May 27, 2026, and reviewed care planning for two residents. Neither had documentation covering their most pressing chronic health problems.
The resident identified in inspection records as R6 had been admitted with a diagnosis of stage four chronic kidney disease, a level of illness that involves severe kidney damage and significant loss of function. The admission assessment identified moderately impaired cognition. Stage four kidney disease commonly causes fluid retention, and R6 arrived at the facility already showing edema.
At some point after admission, a provider order was entered to monitor R6's edema, and that monitoring appeared on the treatment administration record. Then the provider discontinued it and started a nebulizer instead. The edema monitoring came off the record. Nothing replaced it on the care plan.
The weekly weight order, entered May 7, called for weighing R6 every Thursday morning. It said nothing about monitoring for edema.
By the time a nurse noticed the problem, R6 had gained 18.1 pounds. A progress note dated May 25 documented that the provider and nurse manager were contacted about the weight gain. When an inspector observed R6 the following evening, both lower legs were visibly, severely swollen. R6 said that's how they'd been, and that they used to have compression socks at a previous placement but not here.
RN-A, speaking with inspectors on May 27, said she had just noticed the weight gain that past weekend. She described what she found when she assessed R6 that day: diminished lung sounds, and three-plus pitting edema in both lower legs. She said she'd been waiting on new orders and that a Lasix prescription had come through. She said she felt R6's legs had been getting bigger, and that the risks included skin breakdown and the legs beginning to weep fluid.
She also explained what had happened with the monitoring. The provider had discontinued the edema tracking, so it came off the treatment record. But she acknowledged the nurses could have continued assessing it regardless.
The director of nursing agreed. In an interview on May 27, the DON said she would expect nurses to assess the edema and listen to the lungs, and that ongoing monitoring and documentation should have continued and should have been on the care plan. She said that even after the provider discontinued the edema order, monitoring edema remained within a nurse's scope of practice.
It had not been documented. It had not been planned. For a resident with severe kidney disease and a documented history of fluid retention, there was no care plan focus statement for edema management.
The second resident reviewed, identified as R3, had Alzheimer's dementia and was dependent on staff for transferring and toileting. A significant change assessment completed in early 2026 identified constipation as a newly present condition. A care area assessment dated March 9 specifically flagged dehydration and fluid maintenance as triggered concerns, tied in part to that constipation.
R3's medication orders addressed constipation in three separate ways: a bisacodyl suppository to be given if no bowel movement occurred within four days, Miralax once daily as needed, and a senna-docusate tablet once daily as needed. The clinical picture of a resident whose constipation required a standing multi-medication protocol was clear.
The care plan was not updated to reflect it. The care plan dated July 1, 2025 noted that R3 was dependent on staff for toileting needs. There was no focus statement for constipation.
The electronic medical record showed R3 went without a recorded bowel movement from April 6 to April 9, again from April 13 to April 16, again from May 15 to May 18, and again from May 23 through May 27, the day inspectors arrived. Those gaps, some stretching four days, were exactly the threshold that triggered the suppository order. Whether the suppository was given, whether the provider was notified, whether anyone connected the pattern to a care planning gap, the inspection report does not say. What it documents is that across nearly two months, R3 experienced repeated multi-day stretches without a bowel movement, and no care plan existed to guide staff response.
The director of nursing, asked about R3 on May 27, said she would expect constipation to be on the care plan.
The facility's own care planning policy, dated January 3, 2026, described its purpose as ensuring a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs, and stated that assessments were ongoing and care plans were to be revised as conditions changed.
Both residents had conditions that changed. Neither care plan changed with them.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. For R6, still waiting on new orders as the inspection closed, with legs that a nurse said felt like they had been getting bigger for some time, the question of how much harm had accumulated in the gap between the discontinued monitoring order and the day someone finally noticed an 18-pound weight gain was not one the inspection report answered.
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 13, 2026 · Our methodology
NORTH SHORE HEALTH in GRAND MARAIS, MN was cited for violations during a health inspection on May 27, 2026.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on May 27, 2026, and reviewed care planning for two residents.
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.