North Ridge Health And Rehab

F-F693 dated 10/2024 were received and reviewed however neither policy addressed aspiration prevention or the labeling and dating of supplies and solutions for infection prevention purposes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48109 potential for actual harm Based on observation, interview and record review, the facility failed to ensure oxygen order parameters Residents Affected - Few were followed for 1 of 4 residents (Resident R21) and that provider orders for as needed (PRN) oxygen administration were in place for 1 of 4 residents (Resident R204) reviewed for respiratory care.

Findings include:

Resident R21's admission Minimum Data Set (MDS) dated [DATE REDACTED], identified intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. Resident R21's MDS also identified continuous oxygen therapy.

Resident R21's provider orders dated 1/30/25, identified an order for oxygen at 3.5 liters per minute via nasal cannula to keep oxygen saturation levels greater than or equal to 90%.

Review of Resident R21's care plan dated 1/31/25, identified altered respiratory status related to chronic respiratory failure and COPD with an intervention to provide oxygen as ordered.

Review of Resident R21's electronic medical record (EMR) identified oxygen saturation readings from 3/1/25 to 3/6/25 ranging from 92-100%. The oxygen liter flow was not identified at each reading.

During an observation on 3/4/25 at 8:57 a.m., Resident R21 was wearing a nasal cannula which was connected to the oxygen tank, and the dial on the tank was set to five liters.

During an observation on 3/5/25 at 11:43 a.m., Resident R21 was sleeping in his bed wearing an oxygen cannula connected to an oxygen tank with the dial set to five liters.

During an interview on 3/5/25 at 2:52 p.m., registered nurse (RN)-M stated they check oxygen saturation levels every shift for Resident R21, and at that time they should be checking the liter flow and taking a look at the person to see how they are doing. RN-M confirmed the oxygen liter flow for Resident R21 was 3.5 liters, and then went to Resident R21's room and confirmed the dial on the oxygen tank was set to five. RN-M adjusted the oxygen from five down to 3.5, Resident R21's oxygen saturation level was 96%. RN-M explained the risk for Resident R21 having his oxygen too high could be retaining too much carbon dioxide.

During an interview on 3/7/25 at 11:53 a.m., the director of nursing (DON) would expect the liter flow for oxygen was correct when nurses were checking the oxygen saturation level of a resident. The DON stated for Resident R21 this would be important because he had COPD and he could become over-oxygenated.

49878

Resident R204's quarterly Minimum Data Set (MDS) identified resident as being cognitively intact with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in the body), history of throat cancer, chronic obstructive pulmonary disease (lung condition caused by damage to the airways and alveoli of the lungs), moderate protein-calorie malnutrition, emphysema, muscle weakness, and anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0695 During interview on 3/4/25 at 8:28 a.m., Resident R204's room had an oxygen concentrator with connected tubing and

a portable oxygen container. Tubing connected to the oxygen concentrator had a date of 12/30 taped onto it. Level of Harm - Minimal harm or Resident R204 reported he does need oxygen at times but not very often. potential for actual harm Upon record review, Resident R204's orders did not contain any current orders for oxygen administration. Resident R204's Residents Affected - Few discontinued orders identified an order started on 10/21/24 and discontinued on 1/22/25 for resident to be given oxygen at 2-3 liters per minute (LPM) via T-piece (section of tubing in the shape of a T).

During interview on 3/6/24 at 2:24 p.m., licensed practical nurse (LPN)-C verified Resident R204 had oxygen concentrator and portable oxygen in his room. LPN-C indicated Resident R204 does use oxygen but not everyday. LPN-C confirmed there was no active order for oxygen administration in Resident R204's chart.

During interview on 3/6/24 at 2:37 p.m., registered nurse (RN)-H verified Resident R204 had an oxygen concentrator and portable oxygen in his room. RN-H confirmed Resident R204 would use oxygen as needed. RN-H verified Resident R204's medical record did not contain an active order for oxygen administration.

During joint interview on 3/7/24 at 9:51 a.m., director of nursing (DON) and assistant administrator (AA) identified expectation for staff to follow provider orders. DON explained provider orders should be followed in order for the provider and the staff to properly monitor administration and effectiveness of medication or treatment.

Oxygen Administration policy dated 10/2024, identified the purpose was to provide guidelines for safe oxygen administration. Policy indicated the first step was to verify that there is a physicians's order, and ensure the proper flow of oxygen is being administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47495 potential for actual harm Based in observation, interview and document review the facility failed to assess a resident for potential Residents Affected - Few trauma, who was found to have vulvar lesions and under went a Sexual Assault Nurse Examiner exam, in order to implement any potential interventions to ensure Resident R42 was safe and did not have lasting negative effects for 1 of 1 resident (Resident R42) reviewed for trauma informed care.

Findings include:

Resident R42's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R42 had severe cognitive impairment, significant weight loss, lower and upper extremity impairment to one side and required substantial to maximum assistance with toileting and bathing. The MDS further indicated Resident R42 had been admitted to the care facility on 4/1/15.

Resident R42's progress note dated 12/25/24, indicated Resident R42 was found unresponsive in her room and was transferred to the hospital.

Resident R42's progress note dated 1/10/25, indicated Resident R42 arrived back to the facility via stretcher.

Resident R42's hospital discharge summary, dated 1/10/25, indicated Resident R10 was hospitalized from 12/25/24 - 1/10/25 due to a stroke with right sided weakness. Resident R42 was found to have urine retention when admitted to the hospital, when the hospital nurse was catheterizing Resident R42, Resident R42 was noted to have several vulvar lacerations. Resident R42 was evaluated by the Hennepin Assault Response Team and a forensic SANE (sexual assault nurse examiner) exam was completed. The hospital note indicated Resident R42's family member (FM)-E was understandably upset that Resident R42 to return to the care facility but agreed after not being able to find another care facility as long as several safeguards were put in place. The hospital social worker spoke with the clinical director of business (CDB) at the facility regarding the situation who stated Resident R42 was welcome back to

the care facility and due to barriers of finding new placement Resident R42 would return the care facility with safeguards in place.

Resident R42's orders list dated 1/30/25, indicated an order for cares in pairs.

Resident R42's electronic medical record (EMR), including the care plan, Kardex, care conference note, and assessments lacked any indicated of a trauma assessment and, if needed, any updated interventions other than cares in pairs to ensure Resident R42 was safe and did not have any lasting negative effects of triggers from the potential sexual assault and sexual assault examination. The EMR further lacked any mention of Resident R42's stroke, vulvar lesions, and potential trauma from the resulting examinations.

During an interview on 3/6/25 at 11:24 a.m., FM-E stated she had checked in with the facility multiple times since Resident R42 returned from the hospital and was discouraged that the staff didn't even know anything about Resident R42's potential sexual assault and the exam she was subjected to, stating communication at the facility regarding the situation was just horrible. FM-E stated Resident R42 was more responsive when she first returned from

the hospital and seemed more isolated and nonverbal as time went on, stating she (FM-E) could tell it was traumatic for her (Resident R42).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0699 During an interview on 3/6/25 at 10:50 a.m., licensed practical nurse (LPN)-H stated he was aware of the sexual assault allegation and that Resident R42 was cares in pairs and generally he only interacted with Resident R42 to give Level of Harm - Minimal harm or her medications. potential for actual harm

During an interview on 3/6/25 at 12:10 p.m., nurse manager and registered nurse (RN)-F confirmed there Residents Affected - Few was nothing on Resident R42's care plan regarding the potential for continued trauma due to the labial tears and SANE assessment Resident R42 went through, stating Resident R42 was offered a visit by the Associated Clinic of Psychology (ACP) but refused, and Resident R42 was able to communicate with yes or no answers only since her stroke. RN-F stated she was not sure if Resident R42 was ever assessed for residual trauma as that was something the social worker would have done but that with cares in pairs there was an extra set of eyes on her [Resident R42].

During an interview on 3/6/24 at 12:29 p.m., the social worker (SW)-C stated she did not find out about the allegation of sexual assault and resulting SANE assessment until Resident R42's care conference on 1/30/25. SW-C stated she had offered ACP to Resident R42 however was unable to provide documentation and Resident R42's care conference note lacked any documentation of a conversation with Resident R42 and FM-E regarding the allegations and any resulting trauma. SW-C stated she did not do a trauma assessment with Resident R42 because Resident R42 did not acknowledge what had happened. SW-C stated generally if a resident had allegations of sexual assault resulting in a SANE assessment, it would trigger a trauma assessment, and she would be reaching out to the provider to have ACP go in for their own assessment. However, SW-C didn't want to cause more trauma as

she did not believe Resident R42 had been phased by what had happened.

During an interview on 3/6/25 at 1:00 p.m., CDB stated she was aware of the allegation of sexual assault and that the allegation was unsubstantiated against the facility. The CDB stated she was aware that FM-E was apprehensive about Resident R42 returning to the facility due to the potential sexual assault and that FM-E wanted safeguards put in place for Resident R42 when she returned to the facility. The CDB stated the admission coordinator at that time would have been responsible for communicating that information to the floor staff.

During an interview on 3/7/25 at 10:49 a.m., the director of nursing (DON) stated after the facility's own internal investigation they believed the vulvar lesions to perhaps be self-inflicted and not from a sexual assault, however stated she would believe the SANE assessment to be potentialy traumatizing for someone, along with any potential trauma from having a stroke and not being able to fully communicate. The DON stated she was aware FM-E did not want Resident R42 to return to the care facility, stating the facility could have done better by her [Resident R42] by completing a more comprehensive assessment for Resident R42 upon her return from the hospital.

A facility policy titled Clinical Protocol: Trauma-Informed Care, revised 10/22, indicated that residents would be assessed upon admission, quarterly and with a change in condition to determine if they may have new or existing trauma or post traumatic stress disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 42587

Residents Affected - Some Based on observation, interview, and document review, the facility failed to ensure the emergency kits were tracked to prevent potential theft and diversion of medications. This had the potential to affect all residents residing on the nursing unit.

Findings include:

During a tour on 3/5/25 at 11:48 a.m., with registered nurse (RN)-E of the medication room for the 500 wing

the refrigerator had an insulin kit with lorazepam (a benzodiazepine [controlled substance] medication used to treat anxiety) one bottle 2 milligrams per milliliter (mg/ml). RN-E verified the kit was not part of the narcotic count at the change of shift and the box was not secured in the refrigerator.

On 3/7/25 at 8:41 a.m., the director of nursing (DON) stated the emergency kit with insulin and lorazepam did not need to be counted at the shift change because the kit was secured with a green tab that only pharmacy could replace. The DON did however, state when the narcotic count was done staff should have been laying eyes on the box because it wasn't secured in the refrigerator.

The facility policy Controlled Substances dated 10/2024, identified Controlled substances must be stored in

the medication cart in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. If permitted by law, and in accordance with state regulations, the community may store some controlled medications in an emergency medication supply. A reconciliation record will be maintained. In addition, Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the director of Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45842

Residents Affected - Few Based on interview and document review the facility failed to ensure pharmacy consultant recommendations were followed up on in a timely manner for 2 of 5 residents (Resident R183, Resident R204) reviewed for medication management.

Finding included:

Resident R183's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R183 had intact cognition. Resident R13's diagnoses included hypertension, renal failure, diabetes mellitus, and depression.

Resident R183's consultant pharmacist's medication review reports (CPMR) included the following:

- 1/29/25, identified the same recommendation as the one on 9/26/24, because no action was taken. The CPMR was not addressed and signed off until 3/6/25.

- 10/22/24, indicated Resident R183 took Aripiprazole (mental health medication) and Reglan (medication for stomach) which could cause involuntary movements of various parts of the body and lacked an Abnormal Involuntary Movement Scale (AIMS) (assessment to monitor for involuntary movements of the body) had not been documented in the previous 6 months. This CPMR was not addressed until 3/6/25, when the surveyor brought attention to the facility Resident R183's medical record lacked an AIMS assessment.

- 9/26/24, indicated Resident R183 received aspirin daily in the morning and was on dialysis. The clearance of aspirin low dose increased with hemodialysis to the point supplemental dosing or adjustment to the administration time may be necessary. Recommendations was to consider adjusting the of administration of aspirin to the evening/after dialysis. This CPMR was not addressed or signed off as addressed.

During a telephone interview on 3/7/25 at 10:18 a.m., the consulting pharmacist (CP) stated the resident's medications are reviewed monthly and any irregularities or recommendations are to be sent to the facility to be addressed by the director of nursing (DON) or the medical director. The expectations were that it would be done within 30 to 60 days.

During an interview on 3/7/25 at 10:27 a.m., the director of nursing (DON) stated all pharmacy reviews were sent to the assistant director of nursing. The reviews were then given to the unit nurse managers to either be addressed by nursing or given to the provider to be addressed. After being addressed, the completed CPMR would be signed off by the director of nursing. The expectation was all CPMR's would be addressed within a week of receiving or on the providers next rounding day. The DON did confirm Resident R183's CPMR's had not been completed until 3/6/25.

49878

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0756 Resident R204's quarterly Minimum Data Set (MDS) identified resident as being cognitively intact with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in the body), history of throat cancer, Level of Harm - Minimal harm or chronic obstructive pulmonary disease (lung condition caused by damage to the airways and alveoli of the potential for actual harm lungs), moderate protein-calorie malnutrition, emphysema, muscle weakness, and anxiety.

Residents Affected - Few Resident R204's medication orders included orders for aripiprazole (antipsychotic medication) to be given enterally (via tube into the digestive system) once a day for depression. This order began on 10/21/24, was discontinued on 2/18/25, and reordered on 2/19/25.

Resident R204's consultation report dated 1/23/25, identified Resident R204's medication regimen had been reviewed by CP with irregularities found with the order for aripiprazole. CP recommendation included please make sure monitoring is in place: -specific target behaviors, - documentation of the frequency and impact of behaviors, -non-pharmalogical interventions and their outcomes, -potential adverse events and associated monitoring. There was no response from the provider noted.

During interview on 3/7/25 at 10:09 a.m., CP explained she would look at medications for each resident every month. CP reported looking at medications, monitoring, lab work, medical notes, and vital signs from resident's medical record. CP further explained any recommendations would be emailed to the facility, with

the DON and assistant director of nursing (ADON) get the report monthly. CP identified checking previous month's recommendations and would resend recommendations if no provider response within 60 days. CP identified the importance of monitoring any medication for side effects.

During joint interview on 3/7/25 at 9:52 a.m., DON and assistant administrator (AA) stated expectation that pharmacy reviews were done monthly and they were important part of resident's care. DON explained pharmacy medication reviews were helpful to ensure residents were getting medications correctly and providers aware of potential problems from the medications. DON stated expectation for providers to review recommendations from pharmacy consultant and to respond with their acceptance or declination of the recommendation.

The facility's Drug Regimen Review policy was not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure a scheduled antifungal Residents Affected - Few medication without an end date was evaluated for the appropriateness of its continued use for 1 of 6 residents (Resident R129) reviewed for unnecessary medications.

Findings include:

Resident R129's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R129 had severely impaired cognition and was dependent on staff for their activities of daily living (ADLs).

Resident R129's Order Summary Report dated 1/20/25, indicated Resident R129 had an order starting on 4/2/24 with no end date for nystatin (an antifungal medication) powder application to the groin two times a day for a rash.

Resident R129's Medication Administration Report (MAR) dated 1/1/25-3/3/25, indicated Resident R129 had received twice daily applications of nystatin powder during this period.

Resident R129's Weekly Skin Evaluation dated 2/14/25, included a section where staff could check any of the following skin conditions: skin intact, dry, rash, plaques, callouses, redness, skin tears, blisters, open areas, and other. The evaluation had skin intact checked and did not indicate a rash was present.

Resident R129's Weekly Skin Evaluation dated 2/18/25, included a section where staff could check any of the following skin conditions: skin intact, dry, rash, plaques, callouses, redness, skin tears, blisters, open areas, and other. The evaluation had skin intact checked and did not indicate a rash was present.

Resident R129's Weekly Skin Evaluation dated 2/25/25, included a section where staff could check any of the following skin conditions: skin intact, dry, rash, plaques, callouses, redness, skin tears, blisters, open areas, and other. The evaluation had skin intact checked, as well as redness. The evaluation did not indicate where

this redness was located. The evaluation did not indicate a rash was present.

Resident R129's Weekly Skin Evaluation dated 3/4/25, included a section where staff could check any of the following skin conditions: skin intact, dry, rash, plaques, callouses, redness, skin tears, blisters, open areas, and other.

The evaluation had skin intact checked with the comment, no skin issues at this time. The evaluation did not indicate a rash was present.

During an interview on 3/4/25 at 2:47 p.m., registered nurse (RN)-V confirmed she was in charge of applying Resident R129's nystatin powder and Resident R129 did not have any redness or a rash currently. RN-V stated she was unsure about the last time Resident R129 had a rash. RN-V stated she had still applied the Nystatin powder to Resident R129's groin to keep the skin dry but acknowledged rash it was ordered for was now gone.

During an interview and observation on 3/6/25 at 7:53 a.m., the nursing assistant (NA)-G was observed completing personal cares for Resident R129 and confirmed he did not have any redness in his groin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0757 During an interview on 3/6/25 at 12:47 a.m., RN-J, the nurse manager, stated she would expect the nursing staff to either let her know or notify the provider directly if the rash the nystatin powder was ordered for was Level of Harm - Minimal harm or gone, so the order could be discontinued. potential for actual harm

During an interview on 3/7/25 at 9:06 a.m., the infection preventionist (IP) stated if the condition an antifungal Residents Affected - Few was written for had gone away, she would expect the nurse to notify the provider, so they do not give any unnecessary medications or cause the medication to become less effective for the resident.

During an interview on 3/7/25 at 10:15 a.m., the consulting pharmacist (CP) stated if the rash had resolved,

the facility could discontinue the medication as although the risk was low, there were risks of long-term use of antifungal use.

The facility's Infection Prevention and Control Program policy dated 8/24, was received but did not include

the process of antimicrobial monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42587 Residents Affected - Some Based on observation, interview and document review the facility failed to ensure insulin pens were dated when opened and dated with an expiration date for 13 residents (Resident R4, Resident R92, Resident R166, Resident R105, Resident R114, Resident R202, Resident R85, Resident R101, Resident R196, Resident R189, Resident R206, Resident R720, Resident R462) and outdated medications were removed and disposed of properly in 8 of 10 medication carts. In addition, the facility failed to ensure supplies were not outdated, discharged resident medications were properly disposed of for (Resident R721, Resident R722), and medication temperatures were within safe temperature ranges for 8 residents (Resident R2, Resident R29, Resident R71, Resident R30, Resident R91, Resident R92, Resident R109, Resident R149), in 4 of 5 medication rooms. This deficient practice had the potential to affect residents receiving medications from these medication carts and medication rooms.

Findings include:

During a tour on [DATE REDACTED] at 2:06 p.m., with registered nurse (RN)-G at the 3 North medication cart, an aspart insulin pen (rapid-acting insulin used to treat type 1 and type 2 diabetes) for Resident R4 with an open date of [DATE REDACTED], and no expiration date. Humalog insulin (rapid-acting insulin) pen for Resident R92 with an open date of [DATE REDACTED], and a Lantus insulin (long-acting insulin) pen for Resident R166 with an open date of [DATE REDACTED], and an aspart insulin pen with

an open date of [DATE REDACTED]. The insulin pens did not have an expiration date. RN-G pointed to the manufacturer's expiration date and stated the insulin pens would be okay to use until that date.

During a tour on [DATE REDACTED] at 2:29 p.m., with licensed practical nurse (LPN)-D at the medication cart on the memory care unit, Resident R105 had a glargine insulin (long-acting insulin) pen dated as opened on [DATE REDACTED], and no expiration date. Resident R114 had a Humalog insulin pen with an open date of [DATE REDACTED]. LPN-D pointed to the manufacturer's expiration date and stated the pens would be okay to use until that date.

During a tour on [DATE REDACTED] at 2:55 p.m., with LPN-E at the 2 South medication cart a glargine insulin pen for Resident R202 with an open date of [DATE REDACTED], and no expiration date. Resident R202 also had a lispro insulin (rapid-acting insulin) pen with an open date of [DATE REDACTED], and no expiration date. LPN-E stated all insulin pens were good for 27 days after opening. RN-I stated there should have been a list on top of the cart that identified how many days after opening an insulin pen could be used. RN-I looked for the reference, it was not on the cart.

During a tour on [DATE REDACTED] at 3:04 p.m., with RN-E at the 300 medication cart A an aspart insulin pen for Resident R85 had an open date of [DATE REDACTED], and for Resident R101 a Lantus insulin pen opened on [DATE REDACTED], neither pen was dated for expiration.

During a tour on [DATE REDACTED] at 3:16 p.m., with RN-K at the 100 medication cart A insulin pens aspart and Lantus for Resident R196 had open dates of [DATE REDACTED], and no dates for expiration. Resident R189 glargine insulin pen was dated as opened on [DATE REDACTED], and aspart insulin pen was dated as opened on [DATE REDACTED]. RN-K stated all insulin pens were good for 30 days after opening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0761 During a tour on [DATE REDACTED] at 10:59 a.m., with RN-B at medication cart 2 North a stock bottle of famotidine (used to treat ulcers, gastroesophageal reflux and conditions that cause excess stomach acid) with an Level of Harm - Minimal harm or expiration date of ,d+[DATE REDACTED]. RN-B stated the nurse managers were responsible for checking the medication potential for actual harm carts for outdated medications and verified the medication was expired.

Residents Affected - Some During a tour on [DATE REDACTED] at 11:39 a.m., with RN-E at the 500 medication cart a bottle of Novolin insulin (intermediate-acting insulin) for Resident R206 was in the cart. The bottle was open and did not have open or expiration dates.

During a tour on [DATE REDACTED] at 11:57 a.m., with RN-D at the ,d+[DATE REDACTED] medication cart aspart insulin, Novolog (rapid-acting insulin), and Lantus insulin pens were in the medication cart. RN-D verified the insulin pens were not dated with open and expiration dates. Resident R720 (who was no longer a current resident) had a glargine insulin pen also with no open or expiration dates. In addition, the medication cart had two bottles of Geri-Dryl (stock medication [diphenhyrdramine] used to treat pain and itching) with an expiration date of ,d+[DATE REDACTED]. RN-D verified the medication was expired and that insulin pens needed an open date and an expiration date.

A review of Omnicare Storage Recommendations for Injectable Diabetes Medications dated 2023, revealed

the following:

Storage at room temperature after opening

Insulin Aspart - 28 days

Humalog pen - 28 days

Lantus pen - 28 days

Insulin Lispro pen - 28 days

Novolin (R, N, ,d+[DATE REDACTED]) - 42 days

Novolog - 28 days

During a tour on [DATE REDACTED] at 10:59 a.m., with RN-J of the medication room covering rooms ,d+[DATE REDACTED], RN-J stated all insulin pens should be dated with the open date and the expiration date as per the policy. RN-J stated the medication room had been in use for about one year. Five intravenous connectors for Resident R721 were

in bins and were dated as expired on [DATE REDACTED], approximately 10 intravenous caps for Resident R721 expired on [DATE REDACTED], and one intravenous administration set expired on [DATE REDACTED] was also in the medication room. Resident R721 had been admitted on [DATE REDACTED] and discharged on [DATE REDACTED]. For Resident R722, seven heparin flushes with an expiration date of [DATE REDACTED], remained in the medication room. Resident R722 had been admitted on [DATE REDACTED] and discharged on [DATE REDACTED].

During a tour on [DATE REDACTED] at 12:50 a.m., with trained medication aide (TMA)-B in the 2 North medication room

an open box of lubrication jelly packets had an expiration date of [DATE REDACTED], an open box of cotton tip applicators had an expiration date of [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0761 During a tour on [DATE REDACTED] at 2:32 p.m., with LPN-C in the 3 North medication room the refrigerator temperature was at 22 degrees Fahrenheit. LPN-C verified the temperature reading. A review of the past Level of Harm - Minimal harm or three months of temperatures revealed the following dates with temperatures outside of the ,d+[DATE REDACTED] potential for actual harm degree range on the temperature monitoring sheet:

Residents Affected - Some March- (1, 6) lowest temperature reading was 22 degrees F on [DATE REDACTED] at 2:32 p.m., verified by LPN-C.

February- (1, 2, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 24, 26, 27, 28, 29) lowest temperature reading was 30 degrees F.

January - (1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 16, 17, 18, 20, 21, 22, 23, 26, 27, 28, 29, 30) lowest temperature reading was 30 degrees F.

RN-H was present and stated the temperature in the refrigerator should be around 40 degrees F. RN-H verified temperatures that were too cold could to lead to the medication not being viable.

The Refrigerator/Freezer Temperature Log identified the refrigerator temperature range was ,d+[DATE REDACTED] degrees F.

An inventory of the refrigerator revealed the following along with the Omnicare Medication Storage Guidance dated 2023:

Resident R2 one bottle of acetylcysteine inhalation solution 20% - no information

Resident R29 two bottles of lantanoprost ophthalmic solution 0.005% - store in the refrigerator at 36 - 46 degrees F until ready to use.

Resident R71 two bottles of lantanoprost ophthalmic solution 0.005% - store in the refrigerator at 36 - 46 degrees F until ready to use.

Resident R30 two bottles of lorazepam solutions 2 mg/ml - store in the refrigerator at 36 - 46 degrees F. Protect from light.

Resident R91 two Novolog insulin pens - store in the refrigerator at 36- 46 degrees F unopened.

Resident R92 one Lantus insulin pen and two Ozempic pens - store in the refrigerator at 36- 46 degrees F unopened.

Resident R109 one insulin aspart pen - store in the refrigerator at 36- 46 degrees F unopened.

Resident R149 one Dupixent pen - no information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0761 On [DATE REDACTED] at 8:41 a.m., the director of nursing (DON) stated insulin pens should be dated when opened and

the expiration date should be on the pen as well. The DON stated some insulins expire at different number of Level of Harm - Minimal harm or days after opening. The DON stated checking medication carts and medication rooms for expired medication potential for actual harm should be a collaborative effort with purchasing, the nurse manager and the night shift staff on the unit. The DON stated if staff find the medication refrigerator out of the temperature range she would expect them to fill Residents Affected - Some out a slip for maintenance so the refrigerator could be fixed. The DON stated refrigerators needed to be kept

in a certain range to keep medications viable. The DON stated when a resident is discharged their medications and supplies should have been sent with them, returned to pharmacy or destroyed depending

on their payer source.

On [DATE REDACTED] at 10:23 a.m., the consultant pharmacist (CP)-E stated they did periodic spot checks of the medication rooms and the medication carts. CP-E stated it was her expectation as well, that the facility would also be checking for outdated medications and supplies. CP-E stated when staff open an insulin pen they could refer to the chart to see how many days after opening the insulin pen would expire. CP-E stated if a medication refrigerator was out of the safe temperature range she would expect them to follow their facility policy to correct the temperature. CP-E stated if after a few days the refrigerator remained out of the temperature range she would expect them to contact the pharmacy to see if the medications were still viable for use. CP-E stated medications left after a resident was discharged should have been sent home or destroyed properly based on the payer type. CP-E stated she would not expect to find medications from residents discharged several months ago or from 2021.

The facility policy Storage of Medications dated ,d+[DATE REDACTED], identified The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. The policy did not address labeling insulin pens for an open and expiration date. The policy identified Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. The policy did not address medication refrigerator temperatures.

The facility policy Controlled Substances dated ,d+[DATE REDACTED], identified the facility would comply with all laws, regulation, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034 potential for actual harm Based on observation, interview and document review, the facility failed to ensure enhanced barrier Residents Affected - Some precautions (EBP) and/or standard precautions were followed to reduce the risk of infection to others for 2 of 3 residents (Resident R611, Resident R612) reviewed for EBP during tracheal care. In addition, the facility failed to ensure infection control practices were followed regarding tracheal suctioning for 1 of 3 (Resident R612) reviewed for tracheal care. The facility also failed to ensure proper hand sanitization occured during cares for 1 of 3 residents (Resident R97) standard precautions. Also, the facility failed to follow clean procedures when administering tube feedings for 1 of 2 residents (Resident R90) reviewerd for tube feedings.

The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities. The article indicated high-contact activities include changing linens, bathing, dressing, tracheostomy (surgical hole in the windpipe) care, etc. The article indicated EBP should be implemented (when contact precautions did not apply) for residents with indwelling medical devices (central lines, urinary catheter, tracheostomy) regardless of MDRO colonization status.

The CDC article titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated 7/28/24, indicated that when residents require EBP, standard precautions still apply including utilizing face protection when splashes and sprays are likely (e.g., wound irrigation, tracheostomy care).

Resident R611:

Resident R611's admission MDS dated [DATE REDACTED], indicated Resident R611 had intact cognition and was diagnosed with respiratory failure. The MDS indicated that Resident R611 received oxygen therapy, suctioning, and tracheostomy care.

Resident R611's Administration Record dated 3/1/25, indicated Resident R611 had a tracheostomy, tracheal suctioning could be completed as needed, and Resident R611 was on EBP related to an indwelling medical device.

During observation and interview on 3/4/25 at 9:31 a.m., Resident R611 was observed lying in bed as respiratory therapist (RT)-A inserted a suction catheter into Resident R611's tracheostomy tube. RT-A was observed wearing a mask and gloves but no gown or eye protection. RT-A confirmed that she had suctioned Resident R611's tracheostomy and when asked about any additional PPE needs, stated she was moving fast and didn't get to applying any additional PPE although she should have.

Resident R612:

Resident R612's entry tracking record indicated Resident R612 was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 Resident R612's Administration Record dated 3/1/25, indicated Resident R612 had a tracheostomy, tracheal suctioning could be completed as needed, and Resident R612 was on EBP related to an indwelling medical device. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 3/6/25 at 9:11 a.m., RT-A was observed in Resident R612's room wearing a gown, gloves, mask, and no eye protection. RT-A was observed to apply sterile gloves, then remove the Residents Affected - Some nebulizer and using both hands bunch together the nebulizer tubing, then open the resident drawer, and put

the tubing in the drawer. RT-A was then observed to use both hands to move Resident R612's bedside table. RT-A then took off Resident R612's oxygen, removed the tracheostomy inner cannula, and threw it away. RT-A then used both hands to open the package to the sterile suction catheter. RT-A then took the suction catheter out of the package, touching various parts of the catheter before attaching it to the suctioning tubing. RT-A then inserted the catheter into Resident R612's tracheostomy tube and completed suctioning. Resident R612 was observed to cough while suctioning was taking place. RT-A then inserted a new inner cannula, cleaned around the tracheostomy site, took off her gown and gloves, and completed hand hygiene. RT-A confirmed she had, while wearing the sterile gloves, touched various items in Resident R612's room and then used the same gloves to complete tracheal suctioning on Resident R612. RT-A stated as long as she did not touch the end tip of the suction catheter, she did not need to ensure her sterile gloves were kept sterile, so she had not changed them prior to completing suctioning.

During an interview on 3/6/25 at 9:20 a.m., the director of respiratory therapy (DORT)/respiratory therapist, stated that tracheal suctioning was a sterile procedure and expected staff completing this task to keep one hand sterile during the procedure to ensure the suction catheter was also kept sterile before inserting it into

the resident's tracheostomy. The DORT stated if the staff member had contaminated a hand by touching nonsterile items in the room, he would expect them to complete hand hygiene and apply a new pair of gloves

before touching any part of the sterile catheter.

During an interview on 3/6/25 at 1:24 p.m., the infection preventionist (IP) stated that tracheal suctioning needed to be completed as a sterile procedure. The IP stated staff could have a dirty hand and a sterile hand but the hand touching the sterile catheter needed to be kept sterile and was an important part of preventing respiratory infections. The IP stated that gown and glove use as part of EBP should have been utilized during tracheostomy care, but eye protection was only needed if the resident had a respiratory infection or was on droplet precautions, so she did not expect staff to wear eye protection while completing tracheal suctioning.

The facility's Infection Prevention and Control Program policy dated 8/24, was received but did not include instruction regarding EBP or tracheal suctioning.

47263

Resident R97:

Resident R97 significant change Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R97 was severely cognitively impaired. Section O. indicated Resident R97 had been admitted to hospice care. Resident R97's diagnoses included arthritis and non-Alzheimer dementia.

Resident R97's careplan last updated 2/12/25, indicated Resident R97 had been admitted to hospice for palliative care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 During an observation on 3/5/25 at 2:56 p.m., nursing assistant (NA-I) and registered nurse (RN-C) donned PPE and informed Resident R197 they were going to transfer Resident R97 to bed for a brief change. Resident R197 was moved to the Level of Harm - Minimal harm or bed. Both RN-C and NA-I removed their gloves and without sanitizing hands put on new gloves. NA-I potential for actual harm proceeded to use wipes to clean Resident R197's peri area and then NA-I removed Resident R97's old brief. NA-I removed their gloves, brought a box of gloves to the bedside and without sanitizing hands, NA-I put on new gloves while Residents Affected - Some RN-C held Resident R97 on their side. NA-I then placed a clean brief under Resident R97 and Resident R97 was laid flat. RN-C removed their gloves and put on a new pair without sanitizing hands. Resident R97's brief was secured, and a new pad was replaced on Resident R97's bed. RN-C and NA-I removed their gloves and put on new gloves without sanitizing hands and proceeded to transfer Resident R97 back to the chair with the mechanical lift. NA- I and RN-C removed their gown and gloves and left the room. RN-C returned with portable hand sanitizer and sanitized hands upon entering

the room. NA-I returned to the room sanitized hands and moved Resident R97's bedside table and water next to Resident R97. Once out of the room NA-I wiped down the mechanical lift with sanitizing wipes.

During a follow-up interview on 3/5/25 at 3:17 p.m., with NA-I and RN-C both identified they should have been sanitizing their hands every time they took off a set of gloves before they put a new pair on. NA-I stated

they had been in the middle of cares when they noticed there wasn't any hand sanitizer in the room and had decided to finish the cares. RN-C stated in retrospect they should have stopped and got hand sanitizer so

they could sanitize their hands between glove changes. For infection control it was very essential for hand sanitization between glove changes because there could be unseen organisms present that could cause contamination when going from dirty to clean. NA-I agreed it was important to sanitize hands before and after glove changes to prevent infections and contamination.

The facility policy Infection Prevention and Control Program F 880 dated 8/2024, indicated the facility would follow accepted national standards and components of the program would include hand hygiene.

42587

Resident R90:

Resident R90's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R90 had diagnoses which included intestinal malabsorption (a condition that prevents absorption of nutrients through the small intestine), gastrostomy tube status (a flexible, hollow tub inserted through the abdominal wall and into the stomach), malnutrition, diabetes mellitus, anxiety, and depression. Resident R90 was cognitively intact and independent with activities of daily living.

Resident R90's Order Summary Report dated 3/7/25, identified Resident R90 had orders that included the following:

ProStat SF Liquid one time a day for meeting protein needs for malnutrition. Provide via G-tube.

Enteral Feed Orders:

-every night shift change irrigation syringe/bottle, and feeding set up daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 -every night shift site care: clean tube site with warm water and soap, pat dry, apply a dressing if drainage is present, observe for signs and symptoms of infection, for example redness, odor, drainage. Notify the Level of Harm - Minimal harm or primary care provider if needed. potential for actual harm -every shift elevate head of bed at least 30-45 degrees (semi or high-Fowler's position, if tolerated by the Residents Affected - Some residents physical or medical condition) during and for one hour after feeding/medications.

-every shift verify patency and placement prior to feeding/medications. Aspirate small amount of stomach contents to check pH, reading must be less than five.

-four times a day water flush via G-tube, 30 milliliters (ml) before and after each feed providing 240 ml daily.

-one time a day check residual prior to feeding/med. If residual is more than 200 ml or other specifically ordered amount, hold for one hour and recheck. If it still remains high, hold feeding and notify practitioner.

-Hold tube feeding (TF) before and after with Synthroid administration at 6:00 a.m., in the morning for diet.

-Please monitor left lower quadrant feeding site every shift for leakage. Every shift.

-Jevity 1.5 cal/fiber oral liquid (nutritional supplements) give 350 ml via G-tube four times a day for intestinal malabsorption.

Resident R90's care plan dated 8/10/23, identified resident required tube feeding related to malabsorption disorder, malnutrition, roux en Y gastric bypass surgery ( a type of surgery that involves creating a small stomach pouch and rerouting part of the small intestine) and need for PEG J placement (a surgical procedure used to insert a feeding tube into the stomach). Interventions included the following:

-elevate the head of bed at least 30-45 degrees (semi or high-Fowlers position, if tolerated by the resident's physical or medical condition) during and for one hour after feeding/medications

-provide and serve diet as ordered

-provide tube feeding and water flushes ordered. See medical doctor (MD) orders for current feeding orders

A review of Resident R90's nurses notes did not identify the provider had been notified of any redness around the tube feeding site.

On 3/4/25 at 8:39 a.m., in Resident R90's room there was an open bottle of Jevity 1.5 with no date or time. There was also an open bottle of Glucerna (nutritional supplement) with no date or time (Resident R90 did not have TF orders for Glucerna). A used TF bag was hanging with no date on the bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 On 3/5/25 at 12:17 p.m., Resident R90 was lying in her bed, her graduate which contained a syringe was dated 3/5.

The tube feeding bag was hanging on an intravenous (IV) pole, the bag was undated. A bottle of Jevity 1.5 Level of Harm - Minimal harm or had been opened and was dated 3/4/25, no time. potential for actual harm

On 3/5/25 at 2:10 p.m., registered nurse (RN)-B was preparing to administer Resident R90's noon TF. Resident R90 lifted the Residents Affected - Some corner of her shirt a dressing was in place around the G-tube site, it had a brownish substance on the dressing. RN-B filled the graduate with water from the bathroom, placed a few paper towels on Resident R90's room mate's overbed table setting the graduate on the paper towels (room mates juice from lunch was on the tray, RN-B did not clean the overbed table). RN-B checked for residual and tested the pH, flushed the G-tube with 30 ml of water. RN-B used the open Jevity 1.5 dated 3/4/25, but with no time noted on the bottle and poured 350 ml into the TF bag and adjusted the clamp for gravity flow. RN-B removed Resident R90's dressing the site was red in about a one inch circle around the tube. RN-B cleansed the site with skin integrity wound cleanser, Resident R90 winced with the cleaning and said it hurt. RN-B stated she would let the nurse practitioner know. RN-B put supplies away clearing them off of the room mate's overbed table but did not clean the table, the juice remained on the overbed table. RN-B removed her gloves, gown and washed her hands with soap and water.

During an interview on 3/5/25 at 2:25 p.m., RN-B verified the Jevity 1.5 bottle was dated with 3/4/25, and had no time indicating when it had been opened. RN-B verified the Jevity 1.5 was good for 24 hours only. RN-B verified the overbed table she used was Resident R90's room mate's and that she did not clean it before or after using

it for the TF supplies. RN-B could not say how long Resident R90's tube site had been red but thought it had only been

a couple of days .

On 3/5/25 at 2:39 p.m., Resident R90 was not in her bed, the TF had been stopped and the end of the TF was hanging free.

On 3/5/25 at 2:45 p.m., Resident R90 was observed re-connecting her TF.

During an interview on 3/5/25 at 2:49 p.m., Resident R90's room mate stated they always used her table and never cleaned it.

During an interview on 3/5/25 at 3:05 p.m., Resident R90 stated the staff didn't typically throw the TF bag away after each use. Resident R90 stated it usually hung for the day.

During an interview on 3/5/25 at 3:20 p.m., RN- C verified Resident R90 was not on Glucerna and was not sure why it would have been in her room. RN-C also verified TF bottles should have both the date and the time they were opened because they could only be used for 24 hours. RN-C verified staff should not be using the room mates overbed table for TF's for Resident R90, and stated it was an infection control issue. RN-C verified the TF bag should be changed with each tube feeding.

During an interview on 3/6/25 at 12:20 p.m., RN-G verified she had done a TF in the morning but did not change the graduate which was dated 3/5, stated nights should have done that.

During an interview on 3/7/25 at 8:41 a.m., the director of nursing (DON) verified site care should be monitored at each TF and concerns reported to the provider. The DON verified staff should not be using the room mate's overbed table and the TF bottle should have a date and time it was opened to prevent use beyond 24 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0880 The facility policy Gastric Feeding via Continuous Pump dated 5/2024, identified as part of preparation the physician order should be reviewed. In addition, the policy identified the overbed table should be cleaned Level of Harm - Minimal harm or after use and disposable equipment should be discarded. The policy identified any assessments or potential for actual harm complications should be documented. The policy did not address dating and placing a time after opening tube feeding bottles. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 48109 potential for actual harm Based on observation and interview, the facility failed to ensure a complete wireless call system in which Residents Affected - Many staff were provided with functioning devices alerting them to call light activation in their possession. This had

the potential to affect all 250 residents at the facility.

Findings include:

During an observation on 3/5/25 at 2:35 p.m., it was noted there were no call light indicators above the resident rooms on the East side in hallways 500, 600, or 700. At about the middle of each hall there were two scrolling kiosks of about two feet in length and five inches tall, suspended from the ceiling in facing opposite ways. The kiosk displayed the resident room and bed number of the resident who had activated their call light.

During an interview on 3/5/25 at 2:45 p.m., nursing assistant (NA)-E stated she knew when a resident call light went off by the kiosk in the hallway. NA-E stated the NAs didn't carry a pager or anything that alerted her a call light had gone off. NA-E also stated they didn't carry any type of communication, if they were in a room with a resident and needed help, they either had to yell out the door or turn on the call light. NA-E provided the kiosk for this hall also showed the call lights on the 600 hallway, but they didn't show how long

the light had been on.

During an interview on 3/6/25 at 10:09 a.m., RN-F state there was no audible tone for the call lights, they had to watch the board (kiosk). There was a kiosk in the corner of the hall by the nurse's station, so they made sure someone was always at the station to watch for call lights.

During an observation on 3/6/25 at 3:39 p.m., it was noted the second and third floors of the [NAME] building had scrolling kiosks at the ends and middle of the hallways, which displayed the room and bed number of the activated call light.

During an interview on 3/6/25 at 3:51 p.m., registered nurse (RN)-R explained the marque alerts staff to the call lights, but there was no audible tone when activated. RN-R stated the managers carry a pager which will alert when a call light has gone on more than ten minutes, but the other staff didn't have pagers. RN-R added there used to be pagers with the call lights, but after their system crashed the pagers didn't work and

the maintenance person who knew how to reprogram them no longer worked there. RN-R stated staff in a resident room wouldn't necessarily know another call light had gone on without being able to see the kiosk,

they don't carry walkies or other way to communicate, so if staff in a room needed help with a resident, they could either open the door or put the call light on. If they were in a position where they couldn't leave the resident side, they would have to yell.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 66 245183 Department of Health & Human Services Printed: 09/04/2025 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 03/07/2025

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 0919 During an interview on 3/7/25 at 8:42 a.m., the acting administrator (AA) stated the staff knew a call light had been activated by looking at the kiosk in the hallway. AA confirmed there was no audible tone when a call Level of Harm - Minimal harm or light activated. The AA also stated they did have pagers for the system but only the nurse managers carried potential for actual harm those during the day and with the nurse supervisor in the afternoon and overnight. The AA explained there were enough staff on all shifts to see the kiosks, or to have the manager or supervisor alert staff to call lights Residents Affected - Many going off, to have timely responses to call lights.

During an interview on 3/7/25 at 10:07 a.m., the director of campus plant operations (DPO) stated his understanding of the call light system was when a button gets pushed it triggers to the kiosk. The kiosk displayed the room and bed with the call light activation, but there wasn't an audible tone when it activated.

They had pagers at one point, but was not sure what happened to the pagers. The nurse managers have pagers but wasn't aware of how the pagers get programmed. They have some additional pagers, but has handed them off to an administrator previously.

During an interview on 3/7/25 at 10:42 a.m., RN-N confirmed there was one nurse supervisor on afternoons and overnights and that person carried a call light pager which would alert when a call light had gone on longer than ten minutes.

A call light policy and procedure were requested but not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 66 245183