North Ridge Health and Rehab: Skin Care Documentation Failures - MN
The resident, identified in inspection records as R4, was high acuity and high risk. The sites had been red for days before R4 was sent to the emergency department.
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See the Derila PillowWhen inspectors interviewed RN-B on the morning of March 7, the nurse was direct about what had happened. The sites had been red for a few days leading up to the ED visit, RN-B said, so in their view it was not a new skin change. If there was something to document, RN-B said, they would have gone in and made a progress note. They had not.
RN-B also told inspectors they were not the only nurse who had performed dressing changes on R4, and they were not sure whether anyone else had documented R4's skin condition. The nurse manager had been aware of R4's skin as of March 4.
Nobody had written anything down.
The advanced practice registered nurse, identified as APRN-O, told inspectors she had looked at R4's tube feeding site the same day R4 went to the emergency department. Both the tube feeding site and the suprapubic catheter site were red and gunky, she said. Because of R4's high-risk status, she sent R4 to the ED to have the sites and the catheter checked. APRN-O told inspectors that nursing assistants noticing urine or drainage from either site should be reporting it immediately, and that nurses should be documenting and reporting changes to the provider right away.
The director of nursing said the same thing when inspectors asked. Nurses completing dressing changes are responsible for documenting any change in skin condition and notifying the provider, the DON said. Wound assessments should be completed as concerns are found and then weekly. New concerns or changes should be communicated so care can be updated.
That process did not happen for R4.
When the charge nurse, RN-C, pulled up R4's weekly skin assessments during the inspection, neither the February 25 assessment nor the March 5 assessment included any documentation of a new skin occurrence. RN-C told inspectors that once a new wound or skin issue is identified, the identifying nurse is expected to document it and do appropriate follow-up. RN-C also noted, reviewing the flowsheets during the inspection, that R4's suprapubic site still had not been photographed and entered into the wound assessment system so the provider could view it and enter orders.
That review happened after R4 had already been sent to the emergency room.
The facility's own policy on suprapubic catheter care, dated October 2024, instructs staff to inspect the stoma site and surrounding skin for redness or breakdown during every dressing change and to document the results. It also directs staff to notify the physician of any abnormality.
The tube feeding policies told a different story. Inspectors reviewed two separate enteral nutrition policies, one dated October 2024 and one from May 2024. Neither one addressed skin assessment at the tube feeding site at all.
So for R4, the catheter site had a policy that required documentation and notification. The tube feeding site had no policy requiring either. And in practice, neither site was documented, and no provider was notified, until R4's condition had deteriorated enough to require emergency care.
R4's outcome after the ED visit is not described in the inspection record. What the record shows is a gap that ran from at least March 4, when the nurse manager was aware of R4's skin, through the day R4 left for the emergency department, with no documentation created and no physician contacted.
The redness and discharge were visible. Multiple nurses saw it. No one wrote it down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehab from 2025-03-07 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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 12, 2026 · Our methodology
NORTH RIDGE HEALTH AND REHAB in NEW HOPE, MN was cited for violations during a health inspection on March 7, 2025.
The resident, identified in inspection records as R4, was high acuity and high risk.
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.