NEW HOPE, MN — Federal inspectors cited North Ridge Health and Rehab for administering an antipsychotic medication to a cognitively impaired resident without documenting the reason for use or attempting required non-drug interventions, according to a July 2024 inspection report. The facility was also cited for failing to follow CDC pneumococcal vaccination guidelines for multiple residents.
Antipsychotic Given Without Documented Justification
During a federal health inspection completed on July 11, 2024, surveyors found that a resident identified as R184 — a person with moderate cognitive impairment, dementia, and major depressive disorder — received a dose of the antipsychotic medication olanzapine 2.5 milligrams without any documentation explaining why the drug was administered.
The resident's medication records showed an as-needed order for olanzapine for "mood disorder." On one documented occasion, R184 received a dose at 8:03 a.m., but the chart contained no record of non-pharmacological interventions attempted before the drug was given and no documentation identifying what prompted the administration.
Perhaps most concerning, the facility's own behavior tracking records for the resident over the relevant time period showed zero behaviors documented — raising the question of why an antipsychotic was administered at all when no behavioral symptoms were recorded.
Why Antipsychotic Oversight Matters
Antipsychotic medications carry significant risks for elderly residents, particularly those with dementia. The FDA has issued black-box warnings — the most serious type — indicating that antipsychotics are associated with an increased risk of death when used in elderly patients with dementia-related psychosis. These drugs can cause sedation, falls, metabolic changes, stroke, and cardiovascular complications.
Federal regulations under F-758 require nursing facilities to ensure that psychotropic medications, including antipsychotics, are used only when clinically indicated, with appropriate monitoring and documentation. The regulations exist specifically because antipsychotic drugs have historically been overused in nursing homes as a form of chemical restraint — sedating residents to make them easier to manage rather than addressing the underlying causes of behavioral symptoms.
Proper protocol requires that before administering an as-needed antipsychotic, staff must first attempt and document non-pharmacological interventions such as redirection, environmental modifications, one-on-one interaction, music therapy, or addressing unmet needs like pain, hunger, or toileting. Only when these alternatives prove insufficient should medication be considered, and the specific symptoms or behaviors prompting administration must be clearly documented.
Staff Confirmed Gaps in Care Planning
During the inspection, facility staff acknowledged the failures. A registered nurse confirmed that R184's care plan and medication orders did not include alternative non-pharmacological interventions to attempt before giving the as-needed olanzapine. The nurse also confirmed the olanzapine order did not specify what target behaviors or symptoms should trigger administration of the drug.
The facility's director of nursing confirmed that R184's care plan "did not include interventions for R184's behavioral health needs." The DON further acknowledged that as-needed antipsychotic medications should have the indication for use identified in the order on the medication administration record.
The facility's own written policy on psychotropic drug use, reviewed by inspectors, explicitly states that orders for antipsychotic medications should include the target symptoms or condition the medication was ordered for, and that the care plan should address non-pharmacological interventions. The facility was not following its own established protocols.
Additional Medication Concerns
R184's medical records indicated the resident was receiving three categories of psychotropic medications on a regular basis: an antipsychotic, an antidepressant, and a hypnotic sleep medication. The records also noted that a gradual dose reduction had been identified as contraindicated for R184, meaning the resident would remain on these medications indefinitely without periodic attempts to reduce dosages — making proper monitoring and documentation even more critical.
When surveyors requested R184's current medication orders for review, the facility did not provide them.
Pneumococcal Vaccination Tracking Failures
The inspection also identified deficiencies in the facility's vaccination program under F-883. Inspectors found that 3 out of 5 sampled residents (identified as R6, R45, and R202) were not offered or provided pneumococcal vaccinations in accordance with current CDC recommendations.
The CDC updated its pneumococcal vaccination guidelines to include the PCV-20 vaccine, which can provide broader protection against pneumococcal disease — a serious concern for elderly nursing home residents who face elevated risks of pneumonia and related complications. Pneumococcal disease can cause pneumonia, bloodstream infections, and meningitis, and is a leading cause of illness and death among older adults in congregate care settings.
The facility's infection preventionist (IP) told inspectors she was aware of the updated CDC guidelines, including the availability of PCV-20, but stated the shared clinical decision-making process about offering the additional vaccine dose was being left entirely to providers. The IP stated, "As of now, I am not having that discussion."
When inspectors asked the IP to locate residents R6 and R45 in the facility's vaccination tracking spreadsheet, she was unable to find them. After reviewing the CDC guidelines during the interview, the IP confirmed both residents would be eligible for the additional PCV-20 dose. She also verified there were no progress notes indicating any provider had discussed the PCV-20 option with these residents.
For resident R202, a veteran whose immunization records came from the Department of Veterans Affairs, one of the pneumococcal vaccines on record was listed as "unspecified formula," making it difficult to determine proper follow-up vaccination. The IP acknowledged the tracking log listed R202 as not eligible but stated, "The provider would be ultimately the decision maker, it would be up to them to know that about the residents."
Accountability Gap in Vaccination Process
The inspection revealed a pattern of deferred responsibility. The director of nursing told inspectors she was "not real familiar with the facility's process" for vaccinations but believed the provider was driving the shared clinical decision-making. The IP said responsibility defaulted to providers. The result was that no one at the facility was effectively ensuring residents received recommended vaccinations.
Federal regulations require nursing facilities to develop and implement policies and procedures to ensure residents are offered vaccinations in accordance with CDC recommendations. The facility had a written pneumococcal vaccine policy, but the inspection found it was not being effectively implemented.
Broader Context
The use of antipsychotic medications in nursing homes remains a persistent national concern. The Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care in Nursing Homes over a decade ago specifically to reduce the inappropriate use of antipsychotics. While national rates have declined from roughly 24% to approximately 15% of long-stay residents receiving antipsychotics, advocacy groups and regulators continue to identify facilities where documentation and oversight fall short of federal requirements.
Both deficiencies identified at North Ridge Health and Rehab were classified at the level of "minimal harm or potential for actual harm" affecting few residents. While no immediate jeopardy was declared, the violations represent systemic gaps — in medication management documentation and vaccination tracking — that could place vulnerable residents at risk if left unaddressed.
North Ridge Health and Rehab, located at 5430 Boone Avenue North in New Hope, Minnesota, was required to submit a plan of correction to the state survey agency. The full inspection report, including all cited deficiencies and the facility's corrective action plan, is available through the CMS Care Compare database.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehab from 2024-07-11 including all violations, facility responses, and corrective action plans.
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