North Ridge Health and Rehab: Pressure Ulcer Care Failures - MN
The resident, identified in inspection records only as R4, was discharged from a hospital on December 30, 2024. The hospital's notes were clear: R4 had a stage 3 pressure ulcer on the coccyx. A stage 3 wound has broken through the top layers of skin into the tissue beneath. Left unmanaged, it can deepen, tunnel, and become infected.
When inspectors from the Centers for Medicare and Medicaid Services arrived at North Ridge on March 7, 2025, they pulled R4's skin and wound evaluation flow sheets. The first entry documenting anything about R4's coccyx was dated January 22, 2025, more than three weeks after the hospital discharge. And that entry didn't classify the wound as a pressure ulcer. Staff had recorded it as moisture-associated skin damage, a different condition with a different treatment protocol.
The distinction matters. A pressure ulcer requires off-loading, meaning the patient must be repositioned regularly to keep weight off the wound. R4 was not being repositioned every two hours as required. Inspectors found that after care was provided, staff were returning R4 to the same position rather than moving them to a new one. Pressure on the wound, the director of nursing confirmed to inspectors, could worsen it or prevent it from healing entirely.
R4 also never received a pressure-reducing mattress, despite the stage 3 classification that had followed them from the hospital. The wound was never added to R4's care plan. A wound nurse was never consulted.
The facility's own written policy, dated April 2024, spelled out exactly what stage 3 and stage 4 wounds require: protect the wound, manage drainage, promote moist wound healing, address pain. The same policy instructed staff that if a pressure ulcer showed no progression after two to four weeks, the provider should be contacted for new treatment orders. Whether any of that happened for R4 during the weeks the wound went miscategorized, the inspection record does not say.
The APRN who had been involved in R4's care told inspectors they believed wound measures should have been implemented sooner.
The director of nursing, interviewed on the morning of March 7, said she had not been directly involved in R4's care. She reviewed the hospital note during the interview and confirmed it identified the stage 3 wound. She told inspectors her expectations were that all staff, including nursing assistants, should be watching for skin changes and bringing concerns forward. Full skin assessments should happen weekly. When a wound is identified or changes, it should be documented and communicated to the provider so the care plan can be updated. R4's wound, she acknowledged, should have been identified and treated as a pressure ulcer from the start, should have been added to the flow sheet and the care plan, and should have prompted a pressure-reducing mattress and a wound nurse consult much earlier.
When inspectors requested the facility's pressure injury protocols, North Ridge did not provide them.
The inspection classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. That classification reflects the regulatory framework inspectors work within. It does not describe what a stage 3 wound feels like, or what it becomes if the tissue continues to break down without intervention.
R4 spent the weeks after leaving the hospital at a facility that had the records, the policies, and the staff structure to catch what was happening. The wound was there in the hospital notes. The expectations were stated clearly by the director of nursing herself, in the same interview where she confirmed none of them had been met for R4.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 10, 2026 · Our methodology
NORTH RIDGE HEALTH AND REHAB in NEW HOPE, MN was cited for violations during a health inspection on March 7, 2025.
The resident, identified in inspection records only as R4, was discharged from a hospital on December 30, 2024.
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.