North Ridge Health and Rehab: Antipsychotic Oversight Lapse - MN
The resident, identified in inspection records as R204, is a person with a complicated medical history: throat cancer, chronic obstructive pulmonary disease, emphysema, muscle weakness, moderate protein-calorie malnutrition, and anxiety. Since October 2024, R204 had been receiving aripiprazole, an antipsychotic medication, once daily through a feeding tube, prescribed for depression.
Advertisement
Losing sleep over a loved one's care?
The Derila Ergo memory foam pillow supports your neck in any sleep position. 60-day return policy.
See the Derila PillowOn January 23, 2025, a consultant pharmacist reviewed R204's medication regimen and flagged irregularities with the aripiprazole order. The pharmacist's recommendations were specific. Staff needed to document which behaviors the drug was targeting. They needed to record how often those behaviors occurred and what impact they were having. They needed to try non-drug interventions and document whether those worked. And they needed to watch for adverse events and keep records of that monitoring too.
The inspection report notes that no response from the provider was documented.
That silence had a context. R204's care plan, last reviewed on January 9, 2025, listed the resident as taking psychotropic medication for anxiety. The interventions listed were broad: administer medications as ordered, monitor for side effects, talk with the doctor and family about whether the medication was still needed. The care plan also included a list of behaviors to watch for, among them pacing, wandering, disrobing, aggression, and inappropriate responses to verbal communication.
What the care plan did not include was any non-drug approach to managing R204's anxiety.
The pharmacist's January warning essentially identified the same gap. Two weeks before that consultation, the care plan had been reviewed and signed off without addressing it. After the consultation, with the gap now formally documented and a written recommendation sitting in the file, nothing changed.
On February 18, the aripiprazole order was discontinued. The next day, February 19, it was reordered.
When inspectors sat down with North Ridge's director of nursing and assistant administrator on the morning of March 7, both said what any administrator would say. The DON stated that non-pharmacological interventions should be used before medication-based ones. The DON said it was important that residents not take unnecessary medications if it could be avoided.
Those are reasonable principles. They were also, in R204's case, principles the facility had not followed.
The inspection classified the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory framework's assessment of what was documented, not a guarantee that nothing went wrong for R204 during the months aripiprazole was administered without the monitoring the pharmacist said needed to be in place.
Aripiprazole carries a black box warning when used in elderly patients with dementia-related psychosis, the most serious caution the Food and Drug Administration issues. R204's records do not indicate dementia, but the drug's use in older, medically fragile patients requires careful tracking of both effectiveness and side effects. That tracking is precisely what the consultant pharmacist said was missing. That tracking is precisely what the care plan failed to include.
R204 spent months on a powerful psychiatric medication while the file meant to guide that resident's care contained no plan for what to try instead, no record of whether the drug was working, and no documentation of what adverse effects to watch for or whether any appeared. A pharmacist put all of that in writing in January. The provider's response, according to the inspection report, was silence.
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 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.
Since October 2024, R204 had been receiving aripiprazole, an antipsychotic medication, once daily through a feeding tube, prescribed for depression.
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.