North Ridge Health: Sexual Assault Investigation Failures - MN
North Ridge Health and Rehab never conducted a trauma assessment for the 81-year-old woman who had been living at the facility since 2015. The resident, identified as R42 in federal inspection records, was hospitalized in December after being found unresponsive in her room following a stroke.
During hospitalization, when a nurse attempted to catheterize the woman due to urine retention, she discovered several vulvar lacerations. Hospital staff called the Hennepin Assault Response Team and completed a forensic sexual assault nurse examiner exam.
The woman's family member was "understandably upset" about her returning to the facility, according to hospital discharge notes. She agreed only after being unable to find another placement and after requesting that safeguards be put in place.
The facility's response was minimal. Beyond ordering that staff provide care in pairs, North Ridge made no effort to evaluate potential lasting trauma from either the suspected assault or the forensic examination itself.
"She had checked in with the facility multiple times since R42 returned from the hospital and was discouraged that the staff didn't even know anything about R42's potential sexual assault and the exam she was subjected to," the family member told inspectors. "Communication at the facility regarding the situation was just horrible."
The family member noticed changes in the resident after her return. "R42 was more responsive when she first returned from the hospital and seemed more isolated and nonverbal as time went on," she said, adding that she could tell it was traumatic for her.
The facility's own social worker didn't learn about the sexual assault allegation until a care conference on January 30, 2025 — more than three weeks after the resident returned. The social worker said she didn't perform a trauma assessment because the resident "did not acknowledge what had happened."
"Generally if a resident had allegations of sexual assault resulting in a SANE assessment, it would trigger a trauma assessment," the social worker told inspectors. But she said she didn't want to cause more trauma because she didn't believe the resident had been affected by what happened.
The director of nursing acknowledged the facility could have done better. After their internal investigation, staff believed the vulvar lesions might have been self-inflicted rather than from sexual assault. However, she told inspectors that the sexual assault nurse examiner assessment would be "potentially traumatizing for someone, along with any potential trauma from having a stroke and not being able to fully communicate."
North Ridge's own policy required trauma assessments for residents upon admission, quarterly, and with any change in condition. The resident's medical records showed no indication of trauma assessment or updated interventions beyond the pairs of caregivers.
The facility's medication management problems extended far beyond trauma care. Inspectors found a web of violations affecting dozens of residents across multiple areas.
Pharmacy consultant recommendations sat unaddressed for months. One resident's medication review from September 2024 recommended adjusting aspirin timing for a dialysis patient, but staff didn't act on it until March 2025 when inspectors brought it to their attention. Another recommendation about monitoring for involuntary movements went ignored from October until the inspection.
The consulting pharmacist expected recommendations to be addressed within 30 to 60 days. The director of nursing said her expectation was one week.
Oxygen safety failures put respiratory patients at risk. Inspectors found one resident with chronic obstructive pulmonary disease receiving oxygen at five liters per minute when his doctor ordered 3.5 liters. The registered nurse who discovered the error explained that too much oxygen could cause the man to retain carbon dioxide.
Another resident had oxygen equipment in his room but no active medical order for its use. His oxygen order had been discontinued in January, yet staff continued providing access to the equipment.
Medication storage violations were pervasive. Thirteen insulin pens lacked proper expiration dates after opening. Insulin expires 28 to 42 days after opening depending on the type, but staff relied on manufacturer dates that could be months or years away.
Eight medication carts contained expired medications, including some dating to 2021. Two residents who had been discharged months earlier still had supplies sitting in medication rooms.
Temperature control failures compromised medication integrity. One refrigerator holding medications for eight residents ran at 22 degrees Fahrenheit — well below the required 36 to 46 degree range. Temperature logs showed the unit had been out of range for most of January and February.
Infection control breakdowns occurred during the most vulnerable procedures. A respiratory therapist performing tracheal suctioning wore sterile gloves but contaminated them by touching the resident's bedside table, drawer, and nebulizer tubing before inserting the suction catheter.
"Tracheal suctioning was a sterile procedure," the director of respiratory therapy told inspectors. He expected staff to keep one hand sterile throughout the procedure to prevent respiratory infections.
Staff preparing tube feedings used contaminated surfaces and expired nutritional supplements. One nurse placed feeding supplies on a roommate's uncleaned bedside table that still had juice spills from lunch. She used a nutritional bottle dated the previous day but lacking the required time notation to ensure it hadn't exceeded the 24-hour safety limit.
The facility's call light system created delays in emergency response. Staff had no pagers or audible alerts when residents activated call lights. Instead, they relied on visual displays in hallways that showed room numbers. Staff in resident rooms couldn't tell when other residents needed help.
"If they were in a position where they couldn't leave the resident side, they would have to yell," one registered nurse explained.
Only nurse managers carried pagers that alerted them when call lights remained active for more than ten minutes. The acting administrator said there were enough staff to monitor the visual displays, but acknowledged the system had no audible components.
One resident received unnecessary antifungal medication for nearly a year. His nystatin powder order from April 2024 had no end date, and staff continued applying it twice daily even though skin evaluations showed no rash. Weekly assessments in February and March consistently documented intact skin with no indication of the condition the medication was meant to treat.
The consulting pharmacist noted risks from long-term antifungal use and said the medication should be discontinued once the rash resolved.
North Ridge Health and Rehab operates as a 250-bed facility. The March inspection documented violations that federal regulators classified as having minimal harm or potential for actual harm, but the breadth of problems — from sexual assault response to basic medication safety — suggests systemic failures in resident protection.
The family member's assessment of communication being "horrible" appears to reflect broader institutional problems with following through on resident safety protocols and medical recommendations.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
North Ridge Health And Rehab in NEW HOPE, MN was cited for violations during a health inspection on March 7, 2025.
North Ridge Health and Rehab never conducted a trauma assessment for the 81-year-old woman who had been living at the facility since 2015.
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.