North Ridge Health and Rehab: Oxygen Order Lapse - MN
The lapse was documented during a March 2025 federal inspection of the facility at 5430 Boone Avenue North. The resident, identified in inspection records as R204, had held an active order for oxygen at 2 to 3 liters per minute, delivered through a T-piece, a short section of tubing shaped like the letter T. That order had been started on October 21, 2024. It was discontinued on January 22, 2025. After that date, no new order replaced it.
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See the Derila PillowThe equipment stayed in the room. The resident kept using it.
On the afternoon of March 6, a licensed practical nurse identified in records as LPN-C told an inspector that R204 did have an oxygen concentrator and portable oxygen, and that the resident used oxygen, though not every day. When asked about the paperwork behind it, LPN-C confirmed there was no active order for oxygen administration anywhere in the chart.
Thirteen minutes later, a registered nurse identified as RN-H said the same thing. The oxygen was there. The resident used it as needed. There was no active order.
The director of nursing and the assistant administrator were interviewed together the following morning. The director of nursing explained that provider orders exist so that both the provider and the nursing staff can monitor whether a treatment is being given and whether it is working. The expectation, the director said, was for staff to follow those orders.
What went unaddressed in that explanation was the obvious question: if the order had been discontinued in January, and if the expectation was to follow orders, who had been tracking whether R204's oxygen use was appropriate in the weeks since?
Oxygen is not a neutral intervention. Administering it at the wrong flow rate or in the wrong clinical context can cause harm, particularly for patients with certain respiratory conditions. The facility's own oxygen administration policy, dated October 2024, listed verifying a physician's order as the very first step before giving oxygen to any resident. Ensuring the proper flow rate was step two.
Neither step was being followed for R204.
The inspection report does not describe any acute harm to R204 as a result of the lapse. Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that few residents were affected. What the report does not say is how long staff had been aware that the equipment was in use without authorization, or whether anyone had flagged the missing order before inspectors arrived.
The gap between January 22, when the order was discontinued, and March 6, when inspectors first raised the issue with nursing staff, is roughly six weeks. During that time, two nurses who were familiar with R204's care could each confirm, without apparent hesitation, that there was no active order. Neither account suggested surprise. Neither suggested the issue had been escalating toward a fix.
The director of nursing's explanation of why orders matter, given to inspectors the morning after those two nurses confirmed the problem, read less like a response to a specific failure and more like a recitation of general principle. What the provider and the staff are supposed to monitor, the director said, is the administration and effectiveness of treatment.
For six weeks, there was nothing on paper to monitor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehab from 2025-03-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 12, 2026 · Our methodology
NORTH RIDGE HEALTH AND REHAB in NEW HOPE, MN was cited for violations during a health inspection on March 7, 2025.
The lapse was documented during a March 2025 federal inspection of the facility at 5430 Boone Avenue North.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.