North Ridge Health and Rehab: Medication Order Failure - MN
The inspection at North Ridge Health and Rehab, completed March 7, 2025, centered on a single resident identified in records as R97, who was experiencing nausea and vomiting with meals. The prescribed treatment was ondansetron, the generic form of Zofran, a medication the facility's own consulting pharmacist explained needs to be given at least 30 minutes before eating to prevent nausea caused by meals. At 4mg, the drug's half-life runs three to six hours, meaning it clears the body within six to twelve hours of a dose.
The order as transcribed called for two doses a day. A nurse then scheduled those doses for 4:00 p.m. and 8:00 p.m.
That schedule left R97 with no coverage for breakfast and no coverage for lunch.
The consulting pharmacist, interviewed by inspectors on the morning of March 7, was direct about why the order couldn't work. Two doses a day, timed at 4 and 8 in the evening, would be out of the resident's system long before the next morning's meals. The pharmacist said R97 needed four doses daily, timed before breakfast, lunch, and dinner, and at bedtime.
The director of nursing confirmed the sequence of errors during an interview later that same morning. The original transcription was wrong, she said. The medication would have needed to be ordered four times a day to cover all three meals and bedtime. On top of that, the nurse who manually moved the dosing times to 4:00 p.m. and 8:00 p.m. should not have done so without first obtaining a new order from the prescribing provider. Under a standard twice-daily schedule, the doses would have been set for 8:00 a.m. and 8:00 p.m., which still would not have addressed the problem but at least would have followed normal protocol.
The director of nursing said the transcribing nurse would receive education when they returned to work, and that the nurse who changed the times had been instructed to contact the provider for a corrected order.
A registered nurse identified as RN-C told inspectors they were already in the process of reaching out to the provider for a new ondansetron order that would allow four doses a day, timed to give R97 coverage before each meal and at bedtime. RN-C confirmed that the current order, as written and as scheduled, was not producing the therapeutic effect intended. R97 was still experiencing nausea and vomiting with meals.
The facility's own medication order policy, dated June 2024, requires that orders include the type, route, dosage, frequency, and strength of the medication. Inspectors noted the policy says nothing about verbal orders or the process for transcribing orders, the precise gap that allowed the original error to go uncorrected.
CMS classified the violation as causing minimal harm or the potential for actual harm, with few residents affected.
What that classification doesn't capture is the straightforward nature of what happened. A resident was nauseated at meals. A medication existed to treat that nausea. The medication was ordered. Then it was written down wrong, scheduled wrong, and left that way long enough that a pharmacist and a federal inspection team both had to explain to staff why it wasn't working.
R97, by the date of the inspection, had been sitting down to breakfast and lunch with no Zofran in their system, and no one had caught it until the pharmacist did.
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.
At 4mg, the drug's half-life runs three to six hours, meaning it clears the body within six to twelve hours of a dose.
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.