North Ridge Health and Rehab: Restraint Failures - MN
The March 7 inspection found that the facility had placed a physical restraint on the resident to stop him from self-decannulating, the term for removing one's own tracheostomy tube. A nurse identified in the report as RN-J told inspectors that staff had educated the resident on why pulling the tube out was dangerous. But when RN-J went back through the medical record, she could not find documentation that any less restrictive intervention had ever been attempted or even considered before the restraint was applied.
That gap matters. A tracheostomy tube keeps an airway open. Removing it without medical supervision can be life-threatening. The urgency is real. But the inspection found that urgency had become a reason to skip steps, not just move through them quickly.
The director of nursing, interviewed the same morning, acknowledged the dynamic directly. She told inspectors that when a restraint was needed because a resident's behavior could compromise their airway, the situation was treated differently than other restraint decisions. She said residents sometimes arrived from the hospital already restrained, and that interventions might not be attempted before application because of the airway risk and possible adverse outcomes.
That explanation described a pattern, not an isolated lapse.
The director of nursing said she would expect the nurse manager to obtain a physician's order specifying how often the restraint should be removed and how the resident should be monitored for complications from the restraint itself. She said she would expect that order to appear in the administration record and that progress notes would be added if adverse outcomes were observed. She also said she would expect staff to reassess every month whether the restraint was still necessary, and that if it wasn't working, they should look at other options.
What she described as her expectations did not match what inspectors found in the record.
The facility's own restraint policy, dated October 2024, defines a physical restraint as any manual method or device attached to a resident's body that cannot be easily removed and that restricts freedom of movement or normal access to one's body. The policy requires staff to document when the restraint was applied, what type it was, why it was applied, how long it would be used, and each time it was released. Inspectors found the documentation trail on this resident's restraint use was incomplete.
The inspection classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. Those classifications reflect the regulatory scale, not a judgment that a resident being restrained without documented alternatives is a minor matter. A restraint on someone who cannot easily remove it is a physical restriction on a person's body. The threshold for applying one is supposed to be high, and the record-keeping is supposed to prove the threshold was met.
For this resident, the record couldn't prove it.
He had been told not to pull the tube out. He kept pulling it out anyway. Whether anyone sat with him longer, tried a different kind of reminder, adjusted his environment, or consulted with his care team about what else might work, the chart did not show. RN-J looked and came up empty.
The director of nursing described a facility where airway emergencies are treated as a category apart, where the normal deliberation around restraint use gets compressed or skipped because the stakes feel too high to slow down. That reasoning is understandable. It is also, according to the inspection, not a sufficient answer.
The resident remained at the facility. His tube remained a risk. What had been tried, beyond the restraint and the conversation about why he shouldn't do it, was still not in the record.
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.
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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.
A nurse identified in the report as RN-J told inspectors that staff had educated the resident on why pulling the tube out was dangerous.
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.