Cycle 1
Health 2025-03-20 · Fire 2025-03-20
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Duluth, MN
The North Shore Estates Llc
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
7700 Grand Avenue, Duluth, MN
(218) 628-2341
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monarch Healthcare Management
Operator or chain grouping
Approved since
1987-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.68
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,038
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9945
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.50% · Performance 21.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.27
Baseline 6.07% · Performance 5.96% · Measure score 6.27 · Achievement 6.27 · Improvement 0.54
Total nurse turnover
6.72
Performance 36.21% · Measure score 6.72 · Achievement 6.72 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.65
Baseline 3.82 hours · Performance 4.12 hours · Measure score 3.65 · Achievement 3.65 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 10.13% · Lower 95% interval 7.02% |
| Discharge to community | 42.94% |
50.57%
7.6 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 37.31% · Lower 95% interval 32.47% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 22 · Denominator 44 |
| Discharge mobility score | 31.82% |
50.94%
19.1 pts worse
|
Numerator 14 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 64 · Adjusted rate 4.09% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 0% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 16.67% |
8.2%
8.5 pts better
|
Numerator 14 · Denominator 84 |
| Staff flu vaccination coverage | 25.23% |
42%
16.8 pts worse
|
Numerator 27 · Denominator 107 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 20 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 8.33% |
25.2%
16.9 pts worse
|
Numerator 2 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.3%
2.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.9%
1.6 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.2% · Q3 0.0% · Q4 3.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
4.3%
0.3 pts worse
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 11.1% · Q4 4.3% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
4.1%
0.3 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.5% · Q3 7.5% · Q4 0.0% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
12.4%
9.3 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 18.2% · Q3 22.0% · Q4 20.5% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
17.5%
0.6 pts better
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 20.5% · Q3 13.8% · Q4 13.3% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.0% |
22.5%
3.5 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
18.6%
0.4 pts better
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 10.6% · Q3 17.9% · Q4 23.3% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.8% |
2.3%
3.5 pts worse
|
1.0%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.8% · Q3 7.4% · Q4 6.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.6% · Q3 3.8% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
24.8%
4.4 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 24.8% · Q3 38.6% · Q4 26.7% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.4%
3.3 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 10.6% · Q3 8.1% · Q4 1.6% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
88.6%
10.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
14.0%
2.2 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 16.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.9%
1.3 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
82.7%
13.4 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
23.1%
6.5 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 16.7% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-24 · Fire 2023-02-24
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-20
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-02-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-06
F · Potential for more than minimal harm
2023-02-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-03-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-09
F · Potential for more than minimal harm
2024-02-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-02-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-22
F · Potential for more than minimal harm
2023-02-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-24
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
Halpert, Marc
5% Or Greater Indirect Ownership Interest · Individual
Legum, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Spartan Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Yazoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, William
5% Or Greater Direct Ownership Interest · Individual
Arem, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Jaffa, Noam
5% Or Greater Indirect Ownership Interest · Individual
Nij LLC
5% Or Greater Direct Ownership Interest · Organization
Hml LLC
5% Or Greater Direct Ownership Interest · Organization
Muencz, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Halpert, Marc
Corporate Director · Individual
Legum, Joshua
W-2 Managing Employee · Individual
Monarch Healthcare Operating Iv LLC
Operational/Managerial Control · Organization
Stern, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Dove Healthcare - Superior
Superior, WI
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Viewcrest Health Center
Duluth, MN
3-star overall rating with 3-star inspections with $60,781 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Twin Ports Health Services
Superior, WI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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