North Ridge Health And Rehab

F-F676, F 677 policy dated 9/2023, directed the staff to ensure residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The policy also directed the staff to educate the resident of the benefits and risks of not accepting interventions and to document such in the residents medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45842 potential for actual harm Based on interview and document review, the facility failed to ensure residents received timely follow-up Residents Affected - Few treatment and care in accordance with professional standards of practice and provider's recommendations for 1 of 1 residents (Resident R121) reviewed for appointments. The facility also failed to follow provider orders and administer a blood pressure medication only when outside certain parameters for 1 of 1 residents (Resident R40) reviewed for quality of care. Additionally the facility failed to monitor vital signs as ordered for 2 of 3 residents (Resident R73, Resident R138) reviewed for nutrition and recognize nursing staff were documenting colostomy care as being provided to a resident that did not have a colostomy for 1 of 1 resident (Resident R190).

Resident R40's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R57 was severely cognitively impaired. Diagnoses included hypertension and end stage renal disease,

Resident R40's provider orders dated 5/9/24 indicated Resident R40 was started on Midodrine (a medication to increase the blood pressure when low), 5 milligrams (mg) 3 times a day for low blood pressure. Parameters included systolic blood pressure (SBP)- the top number of a blood pressure reading-less than (<) 100 or diastolic blood pressure (DBP)- the bottom number of a blood pressure reading- <60.

Resident R40's electronic medication administration record (EMAR) indicated doses of Midodrine were scheduled for 6:00 a.m., 2:00 p.m. and 8:00 p.m. Documentation indicated Resident R40 received Midodrine at 6:00 a.m., on the following dates: 7/1/24, 7/4/24, 7/5/24, 7/8/24, 7/10/24, and 711/24. Resident R40 received 8:00 p.m. doses of Midodrine on 7/1/24, 7/8/24, and 7/10/24.

Resident R40's documented blood pressure (BP) readings from 7/1/24 to 7/11/24 revealed the following:

-7/1/24, There was no AM time period BP taken and the PM BP was122/67. There were no BPs outside the ordered parameters documented.

-7/4/24, The AM BP was 121/76. There were no BPs outside the parameters documented for the morning blood pressure.

-7/5/24, The AM BP was 120/83.There were no BPs outside the ordered parameters documented for the morning blood pressure.

-7/8/24, The AM BP was 132/81 and the PM BP was 122/60. There were no BPs outside ordered parameters documented.

-7/10/24, The AM BP was113/77 and the PM BP was 122/68. There were no BPs outside ordered parameters documented.

-7/11/24, The AM BP was 119/72. There were no BPs outside the parameters documented for AM shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview on 7/11/24 at 1:59 a.m., registered nurse (RN)-M stated Resident R40 reviewed Resident R40's orders and acknowledged the Midodrine order was 5mg 3 times a day for SBP <100 or DSP <60. RN-K stated that BP Level of Harm - Minimal harm or medication orders that had certain parameters meant the nurse working the cart would check the BP, potential for actual harm document it and then given the medication if outside of the ordered parameters. RN-M reviewed the EMAR and confirmed he had given Resident R40 the Midodrine dosage around 7:15 a.m. When RN-M reviewed the blood Residents Affected - Few pressure readings for 7/11/24, he stated he had taken a different BP reading, but could not produce it or remember it when asked.

During an interview on 7/11/24 at 4:16 p.m., the director of nursing (DON) reviewed Resident R40's medications and BPs documented and stated the Midodrine should not have been given since the BP was higher than they allowable parameters to give the medication. The DON expected all nursing staff would follow the provider orders and only given medication when outside the ordered parameters.

Facility policy Documentation of Medication Administration last revised 9/12 lacked documentation of BP's needed to be taken prior to giving BP medication with parameters and what to do if outside the ordered parameters.

49617

Resident R121:

Resident R121's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated she had moderate cognitive impairment and was taking antibiotics. MDS indicated Resident R121 had diagnoses including infection following a procedure, wound infection, malnutrition, and chronic pain.

Resident R121's current physician orders included the following:

- amoxicillin oral suspension reconstituted 400 milligrams (mg)/5 milliliters (mL), Give 6.3mL enterally (directly into the digestive tract) three times a day for infection, dated 6/24/24.

Resident R121's medication administration record (MAR) dated 6/2024, revealed an order for a 48-72 hour antibiotic re-assessment dated [DATE REDACTED] and discontinued 6/24/24. The MAR also revealed a discontinued antibiotic order for ampicillin-sulbactam sodium (Unasyn) intravenous solution reconstituted 3 (201) gram (GM), to use 2 gram intravenously every 6 hours for sepsis dated 6/2/24 and discontinued 6/18/24.

Resident R121's care plan lacked documentation of antibiotic monitoring.

A progress note dated 6/11/24, indicated Resident R121 left the facility to an infectious disease appointment and was brought to the emergency department and admitted to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 An emergency center note dated 6/11/24, indicated Resident R121's recent history included recurrent falls and multilevel lumbar and cervical spondylosis and stenosis or a narrowing of the spinal canal that can cause Level of Harm - Minimal harm or nerve damage. The emergency center note indicated Resident R121 underwent two spinal surgical procedures and potential for actual harm had a related wound infection with bacteremia (infection in the bloodstream). Furthermore, the note indicated Resident R121 underwent an incision and drainage (I and D) where the infectious disease team found deep surgical Residents Affected - Few site infection. The note indicated after a follow up appointment with the infectious disease team on 6/11/24, Resident R121 had severe back pain and was sent to the emergency department for further evaluation. The note indicated at her infectious disease appointment, the plan was to continue the antibiotic Unasyn through 6/18/24 and start amoxicillin on 6/19/24.

A progress note dated 6/21/24, indicated Resident R121 was readmitted to the nursing facility from the hospital.

A progress note dated 6/25/24, indicated Resident R121 continued antibiotics for infection and her vital signs were within her baseline and she was stable with no concerns noted.

A provider progress note dated 6/25/24, indicated under the assessment and plan header for Resident R121's infection following a procedure, continue to monitor, continue amoxicillin, follow up with infectious disease.

Resident R121's electronic health record (EHR) lacked provider progress note(s) from infectious visit from 6/11/24 or later.

Resident R121's EHR lacked documentation of future appointments scheduled with infectious disease.

During interview on 7/11/24 at 10:20 a.m., licensed practical nursed (LPN)-A stated when a resident is taking

an antibiotic without an end date, usually that resident will have a follow up appointment with their provider to monitor their antibiotic usage. LPN-A stated staff should monitor a resident's vital signs, any reaction to the medication, how the resident is tolerating the medication, any new behaviors or changes to their baseline, and any skin or urine changes. LPN-A stated if there was a change to a resident's baseline, staff should complete a full assessment of the resident, update the provider and document in a progress note. LPN-A stated upcoming appointments are entered into the orders as well as in the calendar of Point Click Care (PCC), the facility's charting system.

During interview on 7/11/24 at 10:37 a.m., registered nurses (RN)-C and D stated they expected staff to monitor vital signs, especially temperatures, changes from a resident's baseline, and anything that could warrant a provider update for residents taking antibiotics. RNs-C and -D stated they reviewed progress notes and provided updates on their residents during daily interdisciplinary team (IDT) meetings. RN-C stated the in-house provider was updated about Resident R121's current antibiotic with no end date and her need for an infectious disease follow-up appointment. RN-C stated the in-house provider deferred to infectious disease. RN-C stated the unit coordinator attempted to schedule an appointment with infectious disease. RN-C and RN-D stated they expected staff to have a turnaround time for appointments as soon as possible and take

the first appointment available, then let the resident and/or their resident representative know and arrange for transportation. RN-C stated, I am 100% she is still working on getting that appointment scheduled. RNs-C and -D stated the medical records (MR) staff person oversaw the unit coordinators.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During interview on 7/11/24 at 11:16 a.m., the infection preventionist (IP) explained the normal process when

a resident returned from an appointment, the unit coordinator would review any paperwork returned with the Level of Harm - Minimal harm or resident and note any new orders and appointments that were or needed to be scheduled before scanning potential for actual harm the paperwork into the resident's chart. The IP verified there were no appointments scheduled for Resident R121, but

she was following with infectious disease. Furthermore, the IP verified there were no recent infectious Residents Affected - Few disease progress notes in Resident R121's EHR. The IP expected the unit coordinator to follow up on appointments with infectious disease.

During interview on 7/11/24 at 2:50 p.m., MR was able to locate the infectious disease progress note for Resident R121 but stated it could not be printed due to computer and printer issues. The progress note dated 6/11/24, indicated the assessment and plan for Resident R121 was to continue Unasyn through 6/18/24 and start amoxicillin on 6/19/24. Consider chronic suppressive therapy. Safety labs reviewed. Counseled the patient about her diagnoses, treatment options, and management of plan. Referral to emergency room by ambulance for pain control of severe low back pain. The progress note lacked follow-up appointment recommendation. MR reviewed Resident R121's EHR and was unable to locate an infectious disease appointment on the calendar in PCC.

During subsequent interview on 7/11/24 at 2:54 p.m., the IP stated they would defer to the facility's in-house provider for Resident R121's ongoing antibiotic use and would re-evaluate her every month.

During subsequent interview on 7/11/24 at 3:06 p.m., the MR and IP stated Resident R121 was seen most recently by

the in-house provider on 6/25/24. They stated they located a faxed order from the in-house provider dated 7/2/24 for Resident R121 to follow-up with infectious disease. The IP showed a calendar view on PCC for Resident R121 that showed an appointment for Resident R121 at Park Nicollet Specialty Center Infectious Disease Appointment on 8/20/24 at 1:30 PM with Dr. [NAME]. The IP was unsure if the calendar view could be printed. The MR stated there was not a way to see when the appointment was made. The MR stated the unit coordinators would not have touched Resident R121's infectious disease note from 6/11/24 because they only handle appointments and new orders. The MR stated someone on the clinical team would have been responsible for reviewing the note and following up on any other recommendations. The MR stated at the time of interview, the note from infectious disease dated 6/11/24 had not been uploaded into Resident R121's EHR. The MR stated it was due to technical trouble and that's the problem with just one of me here to upload everything. The MR verified there was no way for the clinical team to review the infectious disease note from 6/11/24 because there was no way for them to view the note.

During interview on 7/11/24 at 3:47 p.m., the scheduler at Park Nicollet Specialty Center, Infectious Disease stated the appointment for Resident R121 was made on 7/11/24 around 11 a.m. The scheduler stated no other appointments for Resident R121 were previously scheduled or cancelled.

During interview on 711/24 at 3:59 p.m., the director of nursing (DON) stated the expectation after an appointment if there was any paperwork received, it should go to the unit coordinator to review for future appointments and to be uploaded into the resident's chart. However, the DON stated the facility had some difficulties with outside providers and not receiving progress notes and after-visit summaries. The DON stated in those instances, staff could either access the portal or call the provider's office and request the paperwork. The DON stated a recent process change to how follow-up appointments were handle was being implemented but verified the time between Resident R121's last infectious disease appointment and when it was followed up on by staff was lengthy and expected it to be made sooner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Resident R121's infectious disease provider progress notes were requested and not received.

Level of Harm - Minimal harm or A facility appointment policy was requested and not received. potential for actual harm 49035 Residents Affected - Few Resident R73:

Resident R73's quarterly minimum data set (MDS) dated [DATE REDACTED], included Resident R73 had severe cognitive impairment. Resident R73 required partial to moderate assistance with eating and had diagnoses of heart failure, dementia, and depression.

Resident R73's medication administration record (MAR) for June and July 2024, included an order to weigh Monday, Wednesday, and Friday and notify the provider of a 2-pound weight gain in 1 day or a 5 pound weight gain in

a week for a diagnosis of heart failure.

Resident R73's weight was completed and recorded as follows:

7/3/24: 138.3 lbs

6/24/24: 134.5 lbs

6/21/24: 136.1 lbs

6/19/24: 136.4 lbs

6/12/24: 137.5 lbs

6/1/24: 140.1 lbs

Resident R73's record lacked evidence of documentation of weight on the following Mondays, Wednesdays and Fridays:

6/3/24

6/5/24

6/7/24

6/10/24

6/14/24

6/17/24

6/26/24

6/28/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 7/1/24

Level of Harm - Minimal harm or 7/5/24 potential for actual harm 7/8/24 Residents Affected - Few Resident R73's temperature and respiration rate were recorded on 7/7/24, 6/30/24, 6/23/24, 6/16/24, 6/9/24, and 6/2/24.

Resident R138:

Resident R138's quarterly MDS dated [DATE REDACTED], indicated moderate cognitive impairment. Resident R138 had diagnoses of heart failure, hypertension, dementia, and malnutrition and required moderate assistance with eating.

Resident R138's order summary report dated 7/10/24, included to check vital signs daily and assess lung sounds, peripheral edema and measure saturations every morning for heart failure.

Resident R138's Nutritional Quarterly Evaluation dated 4/23/24, included the resident had a weight loss of 5% or more

in the last month or a loss of 10% or more in the last 6 months. The resident was not on a prescribed weight-loss regimen.

Resident R138's weight was last recorded on 6/10/24 at 128.7 lbs. Previous recorded weight was 128.7 lbs on 5/30/24.

During interview on 7/11/24 at 10:51 a.m., registered nurse (RN)-F stated weights were taken once a month for everyone on the unit and document in the electronic medical chart. Some residents would have specific orders for daily or weekly weights from a provider and the dietitian. RN-F confirmed daily vital signs would include more than a blood pressure reading. RN-F confirmed monitoring for fluid overload was part of monitoring for heart failure.

During interview on 7/11/24 at 11:25 a.m., RN-E stated a full set of vitals would include weight, respiration rate, blood pressure, temperature, pulse rate, oxygen saturation and pain. RN-E confirmed Resident R73's last weight was 7/3/24 and Resident R138's last weight was 6/10/24. RN-E had staff obtain weights for both residents. Resident R73's weight on 7/11/24 was 138.0 lbs (down 0.3 lbs since 7/3/24) and Resident R138's weight was 140.7 lbs. ( up 12.0 lbs since 6/10/24).

During interview on 7/11/24 at 11:52 a.m., registered dietitian (RD) stated she would want to check weights every two weeks for someone with a significant weight loss who continued to lose weight or had recently stabilized.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During interview on 7/11/24 at 12:44, director of nursing (DON) stated every resident was to be weighed monthly. The DON confirmed a full set of vitals should include temp, blood pressure, oxygen saturation, Level of Harm - Minimal harm or respiration rate, pulse. Weights should be included for a resident who had heart failure because monitoring potential for actual harm weights is important for monitoring change in condition. DON confirmed there was not an order for weight frequency for Resident R138, but she did have an order for a set of daily vitals. DON confirmed a set of vitals was not Residents Affected - Few completed daily as ordered. DON confirmed Resident R73's last weight was recorded 7/3/24 and was ordered to be completed Monday, Wednesday and Friday, which had not been completed. She stated it was important to monitor for change in condition and worsening heart failure conditions.

47263

Resident R190:

Both Resident R190's quarterly Minimum Data Sets (MDS) dated [DATE REDACTED], and 6/18/24, identified Resident R190 was cognitively intact. Section I active diagnosis included Z93.2 ileostomy status [surgical procedure for a colostomy] [colostomy: surgical opening that connects the lower end of the small intestine to the abdominal wall to allow for intestinal waste to be collected in a pouch outside of the body].

Resident R190's Admission Record face sheet dated 7/11/24 included the following diagnoses: malignant neoplasm of

the bladder and ileostomy status.

Resident R190's electronic medical record (EMR) included an order entered on 12/13/23: Colostomy care every shift and PRN.

Resident R190's Electronic Treatment Records (TAR) included: Colostomy care every shift and PRN. During the period of 12/14/23, to 7/10/24, nursing staff consistently signed off colostomy care had occurred each shift.

Resident R190/s Urology provider notes dated 12/13/23, indicated Resident R190 had had a surgical procedure for a urostomy. Note indicated Resident R190 was passing gas and having BMs. Provider notes lacked evidence of an ileostomy or colostomy.

Resident R190's facility provider visit notes between 1/4/24, and 6/26/24, indicated Resident R190 had a urostomy and lacked evidence of a colostomy.

Resident R190's EMR included a nurse note entered on 7/6/24, that documented Resident R190 had a colostomy and indicated

the nurse had given Resident R190 supplies to collect a stool sample from their colostomy bag.

During an observation/interview on 7/8/24 at 4:53 p.m., Resident R190 had the outline of a pouch under their shirt on

the right side of their torso. Resident R190 touched the area and stated they had to have their bladder removed because of cancer so they had a pouch for urine now.

During a follow-up interview on 7/10/24 at 10:48 a.m., Resident R190 confirmed they did not have a colostomy. Resident R190 stated they used the toilet to have a bowel movement and had a bag to collect urine [urostomy].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview on 7/10/24 at 1:22 p.m., registered nurse (RN)-B stated they provided urostomy care to Resident R190 and documented that on the TAR. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/10/24 at 1:33 p.m., RN-A opened Resident R190's EMR for review and stated Resident R190 had both

a colostomy and a urostomy. RN-A navigated to the TAR and indicated Resident R190 had orders for the care of both Residents Affected - Few the urostomy and the colostomy. RN-A reviewed the TAR and confirmed colostomy care had been signed off as provided each shift to Resident R190 for several months. When informed Resident R190 had indicated they did not have a colostomy, RN-A stated they would have to investigate that and report back.

During a follow-up interview on 7/11/24 at 11:01 a.m., RN-A stated they had reviewed Resident R190's medical record and discussed situation with the director of nursing (DON). RN-A indicated they believed the order for colostomy care was a typo because Resident R190 did not have a colostomy but did have a urostomy. The colostomy order should have been discontinued instead of documented on as completed because Resident R190 did not have a colostomy. RN-A stated it was their expectation that staff would only document on actions and care they had done or provided.

During an interview on 7/11/24 at 2:22 p.m., the DON confirmed Resident R190 did not have a colostomy and indicated the nurse who had entered the order for colostomy care had entered the order in error. The DON stated they had a double nurse sign off incorporated into their order process and they expected this process and or nurse manager review to catch routing and order entry errors before they were released in the EMR.

In this case, nurses should have caught and discontinued the order error right away when it was discovered Resident R190 didn't have a colostomy. The DON stated they did not have an explanation as to why staff had continued to sign off on colostomy care for 7 months when Resident R190 did not have a colostomy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49035 potential for actual harm Based on observation, interview and document review, the facility failed to provide timely assistance in Residents Affected - Few repositioning and toileting for 1 of 1 resident (Resident R138) reviewed for pressure ulcers.

Findings include:

Resident R138's quarterly Minimum Data Set (MDS), dated [DATE REDACTED] included diagnoses of dementia, hemiplegia (weakness on one side of the body), and malnutrition. Resident R138 was dependent for toileting hygiene and dependent for chair to bed transfer. Resident R138's MDS indicated she had moderate cognitive impairment.

Resident R138's care plan dated 5/2/24, identified Resident R138 was incontinent of bladder and required assistance every 2-3 hours for incontinent care to remain free from skin breakdown. Resident R138 had the potential for pressure ulcer development.

During continuous observation on 7/10/24 from 7:35 a.m. to 11:16 a.m., Resident R138 was observed in her wheelchair in the dining room. At 7:35 a.m., Resident R138 was observed at the dining room table waiting for breakfast. At 9:54 a.m., Resident R138 attended an activity in the dining room. At 11:08 a.m., resident remained in the dining room following the activity and had not been approached by staff.

During interview on 7/10/24 at 11:16 a.m., nursing assistant (NA)-C stated she could not remember if she had brought Resident R138 to the bathroom. NA-C did approach Resident R138 to offer toileting, however Resident R138 refused.

During interview on 7/10/24 at 11:21 a.m., registered nurse (RN)-F stated Resident R138 was incontinent and did have a history of pressure ulcers.

During interview on 7/10/24 at 11:29 a.m., RN-E stated residents were assessed to determine how frequently

they were to be toileted. RN-E confirmed Resident R138 had a healed pressure injury. RN-E expected Resident R138 to be toileted every 2-3 hours and if she refused, Resident R138 should be reapproached.

During observation on 7/10/24 at 11:42, RN-E approached Resident R138 to offer toileting and repositioning prior to lunch. Resident R138 agreed and was toileted and repositioned by staff.

During interview at 7/10/24 at 1:48 p.m., director of nursing (DON) confirmed Resident R138 should have been toileted every 2-3 hours. DON stated it was the resident's right to refuse, however residents with memory impairment should have been encouraged and reapproached with refusal. DON stated repositioning and toileting was important to keep skin intact.

Pressure ulcer prevention policy request and not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49654 potential for actual harm Based on observation, interview and document review the facility failed to ensure a post hospitalization Residents Affected - Few assessment was completed for 1 of 1 residents (Resident R45) who had their arteriovenous (AV) access site and hemodialysis treatment discontinued and also failed to ensure post-dialysis monitoring assessments were consistently completed and accurately documented to provide continuity of care and reduce the risk of complications for 3 of 3 residents (Resident R45, Resident R166 and Resident R143) reviewed for dialysis care and services.

Findings include:

Resident R45:

Resident R45's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R45 was cognitively intact, and demonstrated no rejection of care behavior. The MDS indicated Resident R45 was diagnosed with chronic kidney disease with dialysis.

Resident R45's order summary report dated 7/9/24, included the following current orders:

-Hemodialysis (3) times per week on Tuesday, Thursday, and Saturday. Venous access site: care and dressing change during dialysis days and as needed (per dialysis). The order start date was 2/22/24.

-Assess for thrill (a powerful pulse felt at the top of the fistula) and bruit (whooshing sound) each shift. The order start date was 2/22/24.

-Monitor for signs and symptoms of infection at AV shunt, vascular catheter and/or Permacath (a special catheter used for short-term dialysis) every shift. The order start date was 2/23/24.

-Hemodialysis: Permacath Dressing: Do not change unless soiled: change using aseptic technique and place transparent dressing over site (no gauze); keep site dry, sponge baths only (no showers). The order start date was 2/22/24.

Resident R45's care plan dated 6/18/24, identified Resident R45 needed hemodialysis related to renal failure, was at risk for altered nutritional/hydration status related to stage 3 chronic kidney disease and received hemodialysis three times per week. The care plan directed staff to provide interventions which included check and change dressing daily at access site and document. Do not draw blood or take blood pressure in arm with graft. Monitor/document shunt site for abnormal bleeding, bruit and thrill or signs/symptoms of infection. Apply pressure to graft site if bleeding. Monitor/document/report to MD [physician] as needed for signs/symptoms of renal insufficiency, changes in level of consciousness, changes in skin turgor, changes in heart and lung sounds. Monitor/document/report to MD for signs/symptoms of bleeding, hemorrhage, bacteremia, septic shock, fatigue, seizure. Obtain vital sings and weight per protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Review of Resident R45's medical record from 5/23/24 through 6/22/24 revealed Resident R45 received dialysis on 5/23, 5/25, 5/28, 6/1, 6/6, 6/8, 6/11, 6/13, 6/15, 6/18, 6/20, and 6/22. The medical record lacked post dialysis Level of Harm - Minimal harm or assessments for 5/23, 5/28, 6/1, 6/6, 6/8, 6/11, 6/13, 6/15. The post dialysis assessments dated 5/25/24, potential for actual harm 6/18/24, 6/20/24 and 6/22/24 lacked a current weight.

Residents Affected - Few Resident R45's hospital discharge summary dated 7/1/24, indicated Resident R45 was hospitalized on [DATE REDACTED] and discharged

on [DATE REDACTED]. Further, the discharge summary indicated Resident R45 had been treated for an infection of her dialysis access device and it was subsequently surgically removed on 6/25/24. At time of hospital discharge Resident R45 no longer required dialysis treatments. Resident R45's medical record lacked an assessment of Resident R45 upon readmission

the facility and although Resident R45 had her dialysis access device removed and no longer required dialysis treatment, the care plan lacked evidence of being updated with Resident R45's new status or care needs.

Review of Resident R45's Treatment Administration Record (TAR) dated 7/1/24 -7/31/24, indicated Resident R45 had scheduled treatments including assess for thrill and bruit each shift, every shift; Hemodialysis (3) times per week on Tuesday, Thursday and Saturday: venous access site care and dressing change during dialysis days and as needed every shift for dialysis care; Hemodialysis Permacath dressing-do not change unless soiled, change using aseptic technique and place transparent dressing over site (no gauze). Keep site dry, sponge baths only (no showers); Monitor for signs and symptoms of infection at AV shunt, vascular cath and/or perm cath every shift. Site: Right arm every shift for monitoring if bleeding noted from shunt site apply pressure, call 911, notify the MD. Do not remove the dressing from the shunt site; No blood pressure taking and venipuncture on right arm every shift for blood pressure monitoring. Although Resident R45 no longer had a dialysis access device and no longer received dialysis, the TAR identified staff had documented completion of the dialysis related services every shift from 7/1/24 thru 7/9/24. The orders were not discontinued until 7/10/24.

During observation and interview 7/8/24, at 5:57 p.m., Resident R45 was alert and oriented, resting in bed wearing a long-sleeved pink shirt and was covered with a blanket up to her chin. Resident R45 stated she had been hospitalized from 6/24-7/1 with an infection in her dialysis access site.

During interview on 7/10/24 at 8:22 a.m., registered nurse (RN)-N stated when residents returned to the facility after a hospital admission a full head to toe assessment was completed. During the assessment vitals were taken, skin was assessed for changes, and any noted changes were documented in the resident's medical record. RN-N described how to assess a dialysis site for bruit and thrill by listening with a stethoscope and putting fingers over the site to feel the fistula. When reviewing the medical record documentation RN-N confirmed he had documented completing a check for bruit and thrill of Resident R45's fistula on 7/5. He went on to say while taking care of Resident R45 on 7/5, Resident R45 reported she had her access device removed. RN-N could not provide a reason why he documented checking for bruit and thrill and stated, I don't remember why I checked that off.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 During interview on 7/10/24, at 9:08 a.m., kidney unit manager RN-H stated if a resident was hospitalized for 24 hours or more, a full head to toe assessment would be completed by an admission nurse or a floor nurse Level of Harm - Minimal harm or depending on the time and day of the week. The process included reviewing all discharge documents from potential for actual harm the hospital, updating any new orders in the medical record, as well as updating care plans. RN-H stated she routinely reviewed all new and readmission documents for accuracy and to stay on top of everyone. When Residents Affected - Few reviewing Resident R45's discharge summary RN-H confirmed the documents indicated Resident R45 had a surgical removal of her dialysis access device on 6/25 and verified Resident R45's orders pertaining to dialysis care had not been discontinued nor had a readmission assessment been completed, nor the care plan revised after removal of

the access and discontinuation of dialysis. When reviewing Resident R45's TAR documentation for 7/1 thru 7/8 RN-H stated a check mark in the chart would indicate staff completed the task. RN-H confirmed from 7/1 thru 7/8, staff on every shift had documented completion of dialysis related tasks. RN-H stated, staff can't check an access device if it's not there. Additionally, RN-H stated the floor nurses were responsible for reviewing the dialysis communication binder before and after residents had dialysis. If a resident went to dialysis on a day shift, the day shift nurse would document the pre-dialysis vitals and the nurse working when the resident returned would be responsible for the post dialysis assessment and documentation. Upon reviewing Resident R45's medical record RN-H confirmed staff had not completed post dialysis assessments on 5/23, 5/28, 6/1, 6/6, 6/8, 6/11, 6/13, and 6/15.

Resident R166:

Resident R166's admission MDS dated [DATE REDACTED], indicated Resident R166 was cognitively intact, demonstrated no rejection of care behaviors and had a diagnosis of end stage renal failure dependent on renal dialysis treatment.

Resident R166's order summary report dated 7/9/24, included the following current orders:

-Dialysis (3) time per week. Weigh resident and check vitals before and upon return from dialysis. Fill out dialysis form and send to dialysis and review it upon return. Complete post dialysis user defined assessment (UDA). The order start date was 4/9/24.

-Complete post dialysis UDA from assessment drop down manually initiate and complete UDA. The order start date was 4/10/24.

Resident R166's care plan dated 5/9/24, identified Resident R166 needed hemodialysis related to renal failure, was a risk for altered nutrition/hydration status related to end stage renal disease and received hemodialysis three times per week. The care plan directed staff to provide interventions which included check and change dressing daily at access site and document. Monitor shunt site for abnormal bleeding, bruit and thrill or signs and symptoms of infection (redness, swelling, warmth or drainage). Apply pressure to graft site if bleeding. Monitor/document/report to MD as needed for signs and symptoms of renal insufficiency, changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds, peripheral edema. Monitor/document/report to MD as needed for signs/symptoms of bleeding, hemorrhage, bacteremia, septic shock, fatigue, seizures, nausea, pulmonary edema, fever headache, dizziness, diarrhea, hyper/hypotension, flushing, or itching. Obtain vital signs and weight per protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Review of Resident R166's medical record from 6/1/24 through 6/22/24, ok revealed Resident R11 received dialysis on 6/1, 6/4, 6/8, 6/11, 6/13, 6/15, 6/18, 6/20, 6/22, 6/25, 6/29, 7/2, 7/4, 7/6, and 7/9. The medical record lacked post Level of Harm - Minimal harm or dialysis assessments for 6/1, 6/11, 6/13, 6/18, and 6/20. The post dialysis assessment dated [DATE REDACTED] lacked potential for actual harm current weight and vital signs information.

Residents Affected - Few During interview on 7/10/24, at 9:08 a.m., RN-H stated the floor nurses were responsible for reviewing the dialysis communication binder before and after residents had dialysis. If a resident went to dialysis on a day shift, the day shift nurse would document the pre-dialysis vitals and the nurse working when the resident returned would be responsible for the post dialysis assessment and documentation. Upon reviewing Resident R45's medical record RN-H confirmed staff had not completed post dialysis assessments for 6/1, 6/11, 6/13, 6/18, and 6/20.

Resident R143:

Resident R143's quarterly MDS dated [DATE REDACTED] identified Resident R143 was cognitively intact, demonstrated no rejection of care behaviors and had a diagnosis of end stage renal failure dependent on hemodialysis.

Resident R143's care plan dated 5/28/24, identified Resident R143 needed renal dialysis related to renal failure, was at risk for altered skin integrity, nutrition and hydration related to end stage renal disease and received dialysis three days per week. Interventions included encouraging Resident R143 attend all scheduled dialysis treatments, monitor/document shunt site for abnormal bleeding, bruit and thrill or signs/symptoms of infection. Apply pressure to graft site if bleeding; update MD as needed with changes. Monitor/document/report to MD as needed for signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds, peripheral edema. Monitor/document/report to MD as needed for signs/symptoms of the following: Bleeding, hemorrhage, bacteremia, septic shock, fatigue, seizures, nausea, pulmonary edema, fever, headache, dizziness, diarrhea, hyper/hypotension, flushing itching. Obtain vital signs and weight per protocol.

Review of Resident R143's Medication Administration Record (MAR) dated 7/1/24-7/31/24 include the following orders:

-Weigh resident and check vitals before and upon return from dialysis two times a day every Tuesday, Thursday, and Saturday.

-Dialysis three days a week (Tuesday, Thursday, Saturday) Weigh resident and check vitals before and upon return from dialysis. Fill out dialysis form and send to dialysis and review it upon return. Complete post dialysis UDA two times a day every Tuesday, Thursday, and Saturday for hemodialysis. Night staff to get ready for dialysis.

All entries were recorded as complete.

Review of Resident R143's TAR dated 7/1/24-7/31/24 identified Resident R143 had scheduled treatments including Complete post dialysis UDA one time a day every Tuesday, Thursday, and Saturday for post dialysis assessment. All entries were recorded as complete.

Review of Resident R143's medical record indicated Resident R143 received dialysis treatments on 6/1, 6/4, 6/8, 6/11, 6/13, 6/15, 6/18, 6/20, 6/22, 6/25, 6/29, 7/2, 7/4, 7/5, 7/6, and 7/9. The medical record indicated there was no post dialysis assessments completed on 6/1, 6/18, 6/22, 6/25, 7/4, and 7/5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 During observation and interview on 7/8/24, at 06:23 p.m., Resident R143 was lying in bed in pajama's covered with a fuzzy gray blanket. Resident R143 stated she received dialysis three times a week on site. Additionally, Resident R143 rubbed Level of Harm - Minimal harm or her left inner arm and state they never check me after dialysis. potential for actual harm

During interview on 7/10/24, at 09:08 a.m., kidney unit manager RN-H stated floor nurse are responsible for Residents Affected - Few reviewing the dialysis communication binder before and after residents have dialysis. If a resident went to dialysis on a day shift, the day shift nurse would document the pre-dialysis vitals and the nurse working when

the resident returned would be responsible for the post dialysis assessment and documentation. Upon reviewing Resident R143's medical record RN-H confirmed staff had not completed post dialysis assessments on 6/1, 6/18, 6/22, 6/25, 7/4, and 7/5.

During interview on 7/11/24, at 10:00 a.m., director of nursing (DON) stated the facility admission nurses were responsible for completing all admission and re-admissions of residents. If a resident returned on an evening or weekend, one of the floor nurses would be responsible for completing any necessary admission assessments, and a second nurse would review the admission documents and perform a second check to confirm accuracy of new or changed orders. DON stated this would include a full a head-to-toe assessment. DON confirmed Resident R45's record lacked a readmission assessment. While reviewing Resident R45's hospital discharge summary documents DON confirmed the summary indicated Resident R45's dialysis shunt had been removed and Resident R45 was no longer receiving dialysis treatments. She also confirmed Resident R45's dialysis related orders had not been discontinued nor had her care plan been updated to reflect her changes in treatment. Additionally, DON confirmed staff had falsely documented completing dialysis related tasks from 7/1 thru 7/8, and stated she couldn't explain why staff had documented the tasks as completed. DON stated her expectation of staff was to complete assigned tasks and complete all documentation accurately. DON stated this is important for accuracy of the medical record and to prevent any potentially harmful outcomes to the residents. Upon

review of the aforementioned post dialysis assessments for Resident R45, Resident R166 and Resident R143 whose medical record either lacked documentation or the assessments lacked current weights and/or vital sign documentation, DON stated nursing staff were responsible for the accuracy and timeliness of assessments and documentation and she expected all floor nurses to complete assigned tasks and documentation on their shift as this was crucial for patient safety and continuity of care.

The Dialysis, Care for a Resident with

F-F698 policy dated 9/2023 directed resident with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. The policy also directed

the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care including provisions for the cognitively impaired that may impact the safe administration of dialysis including resistance to care, pulling on tubes/access sites, and informing of the practitioner of changes in condition.

The policy further directed upon return from dialysis staff were to document post weight (recommended to come from the center), bleeding at site or other complications or if the resident unable to accept dialysis for any reason.

The Using the Care Plan policy dated 9/2023, directed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. The policy directed changes of condition would be reported to the MDS coordinator for applicable review of the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 During interview on 7/11/24, at 10:00 a.m., director of nursing (DON) stated the facility admission nurses were responsible for completing all admission and re-admissions of residents. DON went on to say if a Level of Harm - Minimal harm or resident returned on an evening or weekend one of the floor nurses would be responsible for completing any potential for actual harm necessary admission assessments, and a second nurse would review the admission documents and perform

a second check to confirm accuracy of new or changed orders. DON stated this would include a full a Residents Affected - Few head-to-toe assessment. While reviewing Resident R45's hospital discharge summary documents DON confirmed the summary indicated Resident R45's dialysis shunt had been removed and Resident R45 was no longer receiving dialysis treatments. Additionally, DON confirmed staff had falsely documented completing dialysis related tasks from 7/1 thru 7/8, and stated she couldn't explain why staff had documented the tasks as completed. DON stated her expectation of staff was to complete assigned tasks and complete all documentation accurately. DON stated this is important for accuracy of the medical record and to prevent any potentially harmful outcomes to

the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47263 potential for actual harm Based on interview and record review the facility failed to develop and implement dementia care as part of Residents Affected - Few the comprehensive care plan for 1 of 3 residents (Resident R184) reviewed for dementia care.

Finding include:

R 184's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], quarterly indicated Resident R184 had moderate cognitive impairment with the diagnoses of chronic obstructive disease, major depressive disorder recurrent, and dementia.

Resident R184's care plan listed as last reviewed on 4/17/24, lacked evidence of individualized interventions to support Resident R184's dementia diagnosis. In addition, the care plan lacked evidence of interventions for mental health needs and management.

During an interview on 7/11/24 at 1046 a.m., registered nurse (RN)-A confirmed Resident R184 had a diagnosis of dementia. After review of the electronic medical record (EMR) and the paper chart, RN-A confirmed Resident R184's care plan did not include interventions for dementia care or mental health needs.

During an interview on 7/11/24 at 2:10 p.m., the director of nursing (DON) stated the care plan should have interventions that are developed specific to the resident to support dementia and mental health needs. The DON confirmed Resident R184's care plan did not include interventions that addressed Resident R184's dementia and behavior health needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 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 Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44651 Residents Affected - Few Based on interview and record review, the facility failed to identify individualized approaches for care, including non-pharmacological interventions to aid in the management of mood and behavior, for 2 of 5 residents (Resident R67, Resident R184) reviewed for unnecessary medications.

Findings include:

Resident R67:

Resident R67's significant change Minimum Data Set (MDS) dated [DATE REDACTED], included Resident R67 was cognitively intact, had diagnoses of Alzheimer's disease and depression, and took antipsychotic and antidepressant medications.

The MDS indicated Resident R67 did not exhibit any behaviors.

Resident R67's provider History and Physical dated [DATE REDACTED], included Resident R67 had severe major depressive disorder with psychotic features.

Resident R67's care plan dated [DATE REDACTED], included Resident R67 used psychotropic medications for behavior management and depression, and Resident R67 had a behavior problem relating to sitting in a chair with a blanket over their head. The care plan lacked resident-specific interventions to address Resident R67's mood and behaviors.

Resident R67's Psychotropic Drug Use Care Area assessment dated [DATE REDACTED], included Resident R67 took olanzapine for mood and Prozac for depression, and nursing staff monitored for side effects and effectiveness.

Resident R67's Medication Administration Record (MAR) dated [DATE REDACTED], included Resident R67 received fluoxetine HCl (Prozac - an antidepressant), 20 milligrams (mg) daily, and olanzapine (an antipsychotic) 5 mg daily at bedtime for mood disorder.

Resident R67's progress notes included the following:

[DATE REDACTED] - Resident R67's spouse died recently and Resident R67 did not have any children.

[DATE REDACTED] - Resident R67's family member informed the facility Resident R67 was grieving the loss of their spouse and was having

a hard time adjusting.

[DATE REDACTED] - Resident R67 was easily irritated with cares and medication administration.

[DATE REDACTED] - Resident R67 was informed they would not be able to return to their assisted living facility.

[DATE REDACTED] at 7:32 a.m., - Resident R67 often covered their head with a blanket while in their chair.

[DATE REDACTED] at 2:56 p.m., - Resident R67 refused to get out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During interview on [DATE REDACTED] at 1:10 p.m., nursing assistant (NA)-B stated if a resident exhibited signs of anxiety or depression, or began having behaviors, they would speak calmly and offer water, and if that didn't Level of Harm - Minimal harm or work, they would inform the nurse. They stated they did not know what worked best to calm each individual potential for actual harm resident, so they just used a soft approach. NA-B stated Resident R67 had some repetitive behaviors such as rummaging through their closet, but they were unaware of any specific interventions in the care plan to help Residents Affected - Few address Resident R67's mood and behaviors.

During interview on [DATE REDACTED] at 1:18 p.m., licensed practical nurse (LPN)-D stated they referred to the care plan to get any helpful hints in addressing a resident's mood and/or behavior issues, and if there was nothing specific, they just tried different things, or talked to other staff who might know the resident better. LPN-D stated they thought Resident R67 was in bed a lot when they first arrived at the facility but was unaware of other behaviors. They reviewed Resident R67's care plan in the electronic record and confirmed it lacked resident-specific interventions.

During interview on [DATE REDACTED] at 1:38 p.m., social worker (SW)-A stated Resident R67 went through a time where it was obvious they weren't doing well after losing their spouse and learning they could not return to their previous home, and indicated the clinical mangers were responsible for updating the care plan with mood and behavior interventions as needed.

During interview on [DATE REDACTED] at 2:21 p.m., registered nurse (RN)-D stated staff referred to the care plan to know what worked best to address residents' mood and behavior concerns. The interventions were based on

the diagnosis at admission and were updated as the staff learned more about the resident over time. They indicated staff could not simply give a medication and expect a psychological condition to go away. RN-D confirmed Resident R67 did not have resident-specific interventions in place and indicated and it was important to help support their mental well-being.

During interview on [DATE REDACTED] at 2:41 p.m., director of nursing (DON) stated it was important to get to know a resident and identify personalized interventions to help relieve symptoms because what works for one person may not work for another. These interventions should be added to the care plan so staff could reference it when needed.

The Psychotropic Drug Use

F-F758 policy dated ,d+[DATE REDACTED], included staff should complete an evaluation of the resident prior to starting a standing order of a psychotropic including non-pharmacological interventions attempted and address in care plan.

47263

Resident R184:

R 184's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R184 had moderate cognitive impairment with the diagnoses of chronic obstructive disease, major depressive disorder recurrent, and dementia. The medication section indicated Resident R184 received antipsychotic, antidepressant, and a hypnotics on

a regular basis. A gradual dose reduction was identified as contraindicated for Resident R184.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Resident R184's electronic medication administration (EMAR) record dated Jun 2024, had an order for the antipsychotic medication olanzapine 2.5 mg [milligrams] give every 24 hours as needed for mood disorder. Level of Harm - Minimal harm or Resident R184 received a prn dose of Olanzapine 2.5 mg on [DATE REDACTED] at 8:03 a.m. The chart lacked documentation of potential for actual harm non-pharmacologic interventions prior to administration and did not identify why Resident R184 had received olanzapine. Residents Affected - Few Resident R184' behavior documentation provied by the facility for the months of [DATE REDACTED], through [DATE REDACTED], had zero behaviors documented.

During an interview on [DATE REDACTED] at 1046 a.m., registered nurse (RN)-A confirmed Resident R184's care plan and orders did not provide alternative non-pharmacological interventions to try prior to the administration of the as needed (PRN) antipsychotic medication olanzapine nor did the olanzapine order indicate what target behaviors/symptoms the prn medication should be administered for.

During an interview on [DATE REDACTED] at 2:10 p.m., the director of nursing (DON) confirmed Resident R184's care plan did not include interventions for Resident R184's behavior health needs. The DON also stated PRN antipsychotic medications should have the indication for use identified in the order on the MAR.

The facility policy Psychotropic Drug Use dated ,d+[DATE REDACTED], indicated orders for antipsychotic medication should include the target symptoms or condition the medication was ordered for, and the care plan should address non-pharmacological interventions.

Resident R184's current orders were requested, but not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49617 potential for actual harm Based on interview and document review, the facility failed to ensure 3 of 5 residents (Resident R6, Resident R45, Resident R202) were Residents Affected - Few offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations.

Findings include:

Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc. gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for:

1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide:

a) the PCV-20 at least 1 year after prior PCV-13,

b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23.

Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old.

2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below:

a) If NO history of vaccination, offer and/or provide:

aa) the PCV-20 OR

bb) PCV-15 followed by PPSV-23 at least 1 year later.

b) For PPSV-23 vaccine ONLY (at any age):

aa) PCV-20 at least 1 year after prior PPSV-23 OR

bb) PCV-15 at least 1 year after prior PPSV-23

c) For PCV-13 vaccine ONLY (at any age):

aa) PCV-20 at least 1 year after prior PCV13 OR

bb) PPSV-23 at least 1 year after prior PCV13

d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years:

aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose

Level of Harm - Minimal harm or e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: potential for actual harm aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 Residents Affected - Few should be administered at least 5 years after the last pneumococcal vaccine.

A review of 5 sampled residents for vaccinations identified 3 of 5 residents (Resident R6, Resident R45, Resident R202) with the following pneumococcal immunization record:

1) Resident R6 was [AGE] years old and was admitted to the facility in April of 2024. Resident R6 previously had the PPSV-23

on 9/19/12, and the PCV-13 on 1/30/15. Based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose regardless of whether PCV20 was administered, her pneumococcal vaccinations were completed.

2) Resident R45 was [AGE] years old and admitted to the facility in February of 2024. Resident R45 previously had the PPSV-23 on 10/1/10, and the PCV-13 on 10/4/19. Based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose regardless of whether PCV20 was administered, her pneumococcal vaccinations were completed.

3) Resident R202 was [AGE] years old and was admitted to the facility in January of 2024. A Department of Veterans Affairs immunization record dated 2/26/24, indicated Resident R202 received pneumococcal, unspecified formul* on 5/11/2010. R 202 received the PCV-13 on 9/18/15.

During interview on 7/11/24 at 11:44 a.m., the infection preventionist (IP) explained the facility's process for determining a resident's vaccination status and eligibility and stated prior to their admission, staff reviewed

the immunization report if they were able to access them. When a resident admitted to the facility, the IP stated they were provided a vaccine information sheet (VIS) and educated on the risks and benefits and then asked if they consented or declined the vaccine. If the resident was able to do so, they could sign the form and if not, their representative could, or they could provide verbal consent or declination. The vaccine was administered and documented in the resident's electronic health record (EHR). The IP stated there was a spreadsheet record of every resident's vaccine status. The IP verbalized being aware of the recent changes to CDC guidelines for pneumococcal vaccinations, including the availability of PCV20 to some residents. The IP stated the shared clinical decision-making piece about the additional PCV20 dose was being left to the providers and stated, As of now, I am not having that discussion. The IP stated the facility's in-house providers had separate immunization visits and encounters.

During subsequent interview on 7/11/24 at 1:42 p.m., the IP was unable to locate Resident R6 or Resident R45 in the spreadsheet tracking log. The IP verified both residents would be eligible for the additional dose when reviewing the CDC guidelines. Furthermore, the IP verified there were no progress notes indicating the provider had conversations about the PCV20 dose. The IP stated, we do not drive that, rather it was left up to the provider. Additionally, the IP stated Resident R202's immunization records were difficult to obtain. The IP verified Resident R202's PCV-13 was entered into the EHR and the other was unspecified. The IP stated the spreadsheed log listed him as not eligible and stated, the provider would be ultimately the decision maker, it would be up to them to know that about the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 During interview on 7/11/24 at 3:39 p.m., the director of nursing (DON) stated most of the immunization responsibility defaulted to the IP to determine a resident's immunization history, what a resident was eligible Level of Harm - Minimal harm or for and obtaining a consent. The DON stated she was not real familiar with the facility's process but believed potential for actual harm the provider was the one driving the shared clinical decision-making process. The DON stated if a resident had an unknown vaccination status or unknown vaccine formula, staff could attempt to reach out to the Residents Affected - Few records department to clarify but it ultimately may be the provider driving that conversation.

A facility policy titled Pneumococcal Vaccine

F-F883 last revised 9/23, indicated residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections (e.g., pneumonia). Before admission,

the policy directed staff to assess a resident's eligibility to receive the pneumococcal vaccine, and when indicated, offer the vaccination unless medical contraindicated or the resident has already been vaccinated. Furthermore, the policy indicated administration of pneumococcal vaccination or re0vaccinations will be made in accordance with current CDC recommendations at the time of the vaccination.

A request for documentation of shared clinical decision making was requested but not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49035

Residents Affected - Some Based on observation and interview, the facility failed to provide a safe, sanitary, comfortable environment for resident on the locked memory care unit. This had the potential to affect all 36 residents, staff and visitors.

Findings Include:

During interview on 7/8/24 at 1:42 p.m., family member (FM)-A stated the facility was always dirty and had

an odor of urine in the hallways. FM-A stated she cleaned Resident R169's room or it would be dirty also.

On 7/8/24 at 3:07 p.m., the carpeted floor in the dining room on the unit was observed to have various crumbs and other debris. An approximately 2 x 2 inch piece of paper that was white and yellow was under one square table. Numerous small, light colored, powder-like spots around the whole room.

On 7/8/24 at 6:30 p.m., Resident R169 was standing in the hallway in the general area outside her room walking, occasionally touching objects such as the door, handrail, and wall.

On 7/9/24 at 1:38 p.m., two light brown spots on the floor approximately 2 inches in diameter close to the wall outside of room [ROOM NUMBER]. Spots are smooth, slight shin in appearance. Wall in room [ROOM NUMBER] across from door was two different colors of paint. Both were a tan color; one is a few shades darker. Approximately half of the wall is painted in the darker brown color. Paint has an uneven edge which ends approximately 1 in to 3 inches from the ceiling, wall to the side and baseboard.

On 7/9/24 at 1:42 p.m., a housekeeping staff member was vacuuming the dining room. Two residents were

in the room during vacuuming.

On 7/9/24 at 1:42 p.m., numerous off white and tan spots in various sizes of 1 to 2 inches were observed on

the carpet scattered throughout the whole room, but more concentrated around the tables. An approximately 4-foot section of wallpaper was missing in the corner under a window. On wall where wallpaper was missing, multiple dried dark brown stains are present including opaque brown streaks running in a downward manor.

On 7/9/24 at 2:29 p.m., an approximately 1/2 inch in diameter dark brown spot with a 2-inch lighter smeared spot was on the handrail by room [ROOM NUMBER]. Approximately 1 foot to the side of the dark brown spot were light brown drip like streaks coving approximately a 2-foot area.

On 7/10/24 at 7:28 a.m., the brown darker spot with smear by room [ROOM NUMBER] was still on handrail. Light brown drip-like streaks also remain. Section of carpet between dining room doors to room [ROOM NUMBER] going out approximately 2.5 feet from wall feel tacky when walked on. No discoloration noted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 245183 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245183 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Ridge Health and Rehab 5430 Boone Avenue North New Hope, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 On 7/10/24 at 9:51 a.m., activity staff were starting to prepare for an activity in the dining room. Tables were not wiped down after breakfast before activity started. Level of Harm - Minimal harm or potential for actual harm During interview on 7/11/24 at 8:04 a.m., registered nurse (RN)-F housekeeping is on the unit every day. It was everyone's job to help clean the unit. RN-F stated she made sure the tables were clean after meals. Residents Affected - Some RN-F confirmed there were two light brown spots on the floor approximately 2 inches in diameter close to the wall outside of room [ROOM NUMBER]. RN-F stated the area could not be cleaned because it was like glue now. RN-F confirmed the brown smear on the handrail by room [ROOM NUMBER]. She stated it was a new mark and housekeeping would clean. RN-F stated it must have been chocolate pudding or a chocolate ice cream desert and described it as handprint in size, about two fingers. RN-F used wet soapy paper towels to clean area. RN-F stated it was important to have the handrail clean because residents often though that area.

During interview on 7/11/24 at 8:12 a.m., RN-E confirmed the carpet outside of the dining room felt sticky and described the two light brown spots outside of room [ROOM NUMBER] at a spilled supplement from a medication pass. RN-E stated there is a carpet cleaner on site and she would get them up to clean it.

During interview on 7/11/24 at 8:21 a.m., Direct of housekeeping stated she does spot checks on the units daily. She stated the staff are instructed to wipe down hand railings daily, flat mop the walls weekly and as needed, vacuum the floor in the dining room after breakfast, whip down tables daily after breakfast and lunch. Director of housekeeping confirmed there was crumbs and food particles on the floor after breakfast. Direct of housekeeping confirmed there was a 4-foot piece of wallpaper missing and the exposed wall had both liquid and solid spilled on the wall and stated the wallpaper is old and needs to be replaced. Director of housekeeping confirmed spots on carpet outside of room [ROOM NUMBER] and that the carpet felt sticky outside of the dining room. She stated staff should have been able to clean spots off the floor. Direct of nursing confirmed the handrails needed to be cleaned and should have been done daily. She stated it was important to clean and disinfect daily because this was their home, and the facility needed to make sure they have a safe clean area to live.

During interview on 7/11/24 at 8:56 a.m., administrator stated the carpet on the unit needed to be replaced and that there had been discussion but no solid timeline. The administrator confirmed the wallpaper in room [ROOM NUMBER] was not satisfactory or homelike and confirmed the color was not a match. The administrator stated the facility was working on replacing a few non-functioning exhaust fans which was the cause of the odor on the unit. He stated the facility was still obtaining quotes for the exhaust fans. The administrator confirmed there were rips and missing pieces of wallpaper in the dining room and stated the wallpaper in the whole building needs to be replaced but that was a massive undertaking. He stated it was not a homelike or welcoming environment. The administrator confirmed a few handrailings were missing endcaps, which caused them to have a blunt edge and could lead to injury. He stated he would have expected a work order to be put in as critical and for the issue to be fixed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 245183