Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Estates At Fridley Llc during CMS and state inspections, most recent first.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
The facility failed to implement effective pest control, resulting in an ongoing mouse infestation reported by multiple residents and observed by staff. A resident with pressure ulcers reported repeated mouse sightings in her room, while others described seeing mice frequently, finding dead mice among personal belongings, and hearing mice in the walls. Food was stored in resident rooms and in cluttered conditions, including bags and totes stacked on beds and in corners, and one resident used his own rat/mouse poison trays in his room. Staff, including an RN, the maintenance director, the dietary manager, and therapy staff, acknowledged a mouse problem in resident areas, the breakroom, and a therapy storage area where food had been hidden and droppings seen. Although an external pest control company was under contract, a scheduled visit was missed due to lack of supplies, and the facility’s own pest control policy requiring an ongoing program to keep the building free of rodents was not effectively carried out.
A resident with moderate cognitive impairment, Wernicke’s encephalopathy, alcoholic cirrhosis, and alcoholism not in remission had an elopement risk score of 4 and was under civil commitment, but the care plan did not include either focus area. SSD, RN, and DON all acknowledged the missing care plan guidance, and the elopement policy required documentation of wandering or exit risk and measures to prevent elopement.
Inaccurate elopement risk assessments were completed for two residents. One resident with moderate cognitive impairment, Wernicke's encephalopathy, and alcoholism had an assessment that did not accurately reflect cognitive deficits or prescribed quetiapine, and the care plan lacked elopement-related direction. Another resident with hepatic encephalopathy and quetiapine was scored only for ambulation, while confusion and psychotropic medication use were omitted. The RN acknowledged the assessments were not completed accurately, and the DON confirmed the errors.
Failure to Include Cervical Collar Care in Baseline Care Plan: A resident admitted with a cervical spine fracture and Aspen C-collar did not have collar-specific interventions in the baseline care plan, and the TAR also lacked orders for collar care, skin checks, or removal guidance. The resident reported staff had not cleaned the skin under the collar or changed the padding, and an RN stated she had never removed the collar. When the collar was removed during observation with two staff assisting, the skin underneath was red but intact.
Failure to assess and document cervical collar care for a resident with a cervical fracture. The resident’s hospital discharge instructions required the Aspen collar to stay on except as directed, with skin care and documentation every 8 hours, neuro checks, and daily pad changes. However, the care plan and TAR did not include the collar orders, staff did not document routine skin checks under the collar, and the resident reported staff had not washed the skin or changed the padding. During observation, the collar was removed with assistance and the skin underneath was red.
A resident with a history of substance abuse and recent methamphetamine use exhibited escalating aggressive behaviors, including vandalism and physical assault on another resident who was cognitively impaired and required supervision. Despite multiple incidents of erratic and violent behavior, the facility did not adequately reassess or update interventions for the resident's mental health needs, nor did it consistently document safety checks or targeted interventions, resulting in a failure to protect a resident from abuse.
A resident with a history of alcohol abuse, trauma, and mental health disorders did not receive adequate mental health and psychosocial services. The care plan lacked person-centered interventions, measurable goals, and support for autonomy or community connections. The resident's mental health declined, resulting in aggressive behaviors, substance use, and multiple hospitalizations, while staff failed to provide or document appropriate therapeutic or chemical dependency interventions.
A resident with ESRD, fluid overload, seizures, HTN, CVA, and pulmonary edema had an albuterol inhaler and Ocean nasal spray labeled with the resident's name observed at the bedside, but the chart lacked a self-administration assessment and orders for self-administration or bedside medications. An RN and the DON confirmed there was no SAM order and no order for the nasal spray, and the DON stated the resident needed to be assessed and found competent before self-administering medications.
Missing Ombudsman Notification for Hospital Transfers: The facility failed to send written transfer notices to the LTC Ombudsman for two residents who were hospitalized. One resident had paraplegia, a wound, PE, neurogenic bladder/bowel, and sepsis; the other had ESRD, fluid overload, seizures, HTN, CVA, and pulmonary edema. The administrator confirmed the prior SW did not complete the Ombudsman notifications, and the facility policy required the notice to be sent at the same time as the resident transfer/discharge notice.
A resident with psychotic disorder and depression had lorazepam ordered for terminal agitation, but the MAR documented oral tablets while the narcotic book documented liquid medication for the same administrations. RN and DON interviews confirmed staff were expected to verify the five rights and obtain a new order before changing from tablet to liquid form, and the CP confirmed a new order was required for that change.
A resident receiving hemodialysis had a breakdown in communication between the facility and the dialysis center. The resident had ESRD-related diagnoses, was cognitively intact, and had orders for dialysis-related monitoring and a communication form to accompany each treatment. However, an RN stated she did not routinely send the form unless there was a change, did not send it for one dialysis trip, and would not call for updates if the form was not returned. The dialysis binder lacked completed forms for multiple months, and the DON confirmed the forms had not actually been completed since May despite EMR documentation suggesting otherwise.
Improper Disposal of Controlled Medications After Resident Discharge: The facility failed to dispose of controlled meds for two residents after discharge/death. During a med room tour, the ADON found lorazepam for both residents still stored in the refrigerated controlled-substance lock box; one resident’s narcotic tracking was missing from the current book and found in an unused book, and the other resident’s lorazepam remained on hand after the resident died in the facility. The DON and CP stated controlled meds should be destroyed/disposed of after a resident discharges or passes away, and facility policy required disposal by two licensed nurses with documentation in a record book.
Improper Storage of Refrigerated Controlled Medications: Controlled refrigerated medications were found in a lockbox inside an unlocked medication refrigerator, but the lockbox was not permanently affixed to the refrigerator. The ADON and DON confirmed the box could be removed and that the facility had not yet secured it in a fixed compartment, while the CP stated controlled substances should be stored in a permanently affixed double-lock compartment to prevent diversion. The facility policy required the locked box in the refrigerator to be attached to the inside of the refrigerator.
A deficiency was found when an LPN failed to perform hand hygiene between glove changes while providing wound care to a resident with cognitive impairment and skin wounds. The LPN changed gloves multiple times without sanitizing hands, contrary to the care plan and facility policy. The DON confirmed that hand hygiene was not performed as required during the procedure.
A nursing assistant did not receive a required annual performance review, as confirmed by both the staff member and the DON. The facility also lacked a policy on performance reviews, and this lapse had the potential to impact all residents under the care of this staff member.
A resident's allegation of rough care by a nursing assistant, resulting in pain, was not reported by facility staff to the State Agency within the required two-hour timeframe. Although the incident was reported to authorities by an outside party, facility staff did not submit a separate report as mandated by policy, and interviews revealed confusion among staff regarding proper reporting procedures.
The facility failed to ensure an RN was scheduled for a minimum of 8 consecutive hours a day, affecting all 35 residents. The ADON and DON, who are RNs, were not included in the regular schedule and were only on call during weekends. The facility had difficulty hiring RNs and did not have a staffing policy, leading to situations where LPNs had to call the on-call physician or the ADON/DON for assistance.
A resident with multiple medical conditions did not receive ordered podiatry care, resulting in long, thickened, and dirty toenails. Staff were unsure about the last nail care provided, and there was confusion about the eligibility of transitional care unit residents for podiatry services.
A facility failed to ensure a resident received prescribed medication for skin picking, resulting in 15 missed doses. Staff interviews revealed lapses in ordering and follow-up procedures, with the BOM unsure if the medication was ordered and the RN acknowledging the delay. The DON stated that medications should be obtained promptly, but the facility did not follow through.
The facility failed to ensure timely implementation of pharmacist recommendations for a resident on antiplatelet medication and with hyperlipidemia. The pharmacist's repeated recommendations for a lipid panel were not addressed for several months, and the resident's care plan lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. The DON confirmed the missed orders and the facility's policy on pharmacy MRRs was not provided.
The facility failed to ensure proper use and documentation of antipsychotic medications for two residents. One resident was prescribed Seroquel for insomnia without adequate medical justification or a discussion of risks and benefits. Another resident's medical record lacked behavior tracking and non-pharmacological interventions before administering PRN antipsychotic medication. Staff interviews revealed a lack of awareness regarding regulations related to antipsychotic administration.
The facility failed to ensure that a resident with a history of chronic lung disease and other conditions was offered or received the pneumococcal vaccine according to CDC recommendations. The assistant director of nursing assumed the resident was up to date based on existing documentation, but no clinical decision-making discussion occurred as required.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Implement Effective Pest Control for Mouse Infestation
Penalty
Summary
Failure to implement effective and timely pest control measures resulted in an ongoing mouse infestation affecting resident rooms and common areas. Multiple residents reported frequently seeing mice in their rooms, including one resident who stated she sees mice "all of the time" and recently observed a mouse running from her room into the hallway. Another resident reported seeing mice in her room on approximately ten different occasions and overheard a nurse say a mouse was seen coming out of a power outlet. This resident also had pressure ulcers on her coccyx and expressed concern about the mouse infestation. Observations showed food stored in resident rooms, including food in containers and bags on a nightstand, and clutter such as stacked plastic totes, bags of clothing, and miscellaneous items on beds and in rooms. Residents described taking their own measures to address the mice, including one resident who kept Rat/Mice X products in his walker seat and placed them in the corners of his room, and another who found a dead mouse between stacked plastic totes and removed it herself. That same resident reported a mouse caught in a sticky trap that she moved to a hallway garbage can, and described watching two baby mice playing on her floor by her bed and hearing mice in the walls at night. Staff interviews corroborated the infestation, with an RN reporting seeing mice in the breakroom and hearing resident complaints of mice in rooms. A physical therapy assistant reported a broken bed in a back hallway piled with old wheelchair parts and bags of unknown items, and stated she had observed a resident who liked to store food in that bed and had seen mouse droppings there. The maintenance director acknowledged awareness of a mouse problem in the building for almost a year and stated it worsened during cold weather. He reported that an outside pest control company visits monthly and as needed, and that nurses are instructed to document mouse sightings in a book for targeted treatment. However, he and the administrator both stated that a recent pest control visit did not occur as planned because the company reported being out of bait and products. The dietary manager confirmed there was a mouse problem and stated more proactive treatment was needed, noting that mice had been trapped in a live trap under the three-compartment sink in the kitchen, although she had not personally seen mice or droppings in the kitchen and food there was contained. The facility’s pest control policy required an ongoing program to keep the building free of insects and rodents and prohibited accumulation of garbage and trash, but the observed mouse activity, resident reports, cluttered rooms and storage areas, and reliance on residents’ own pest control efforts demonstrated that effective pest control measures were not implemented.
Care Plan Missing Elopement Risk and Civil Commitment
Penalty
Summary
The facility failed to ensure the comprehensive care plan was updated to include elopement risk and civil commitment for one resident. The resident’s admission MDS indicated moderate cognitive impairment and diagnoses of Wernicke’s encephalopathy, alcoholic cirrhosis of the liver, and alcoholism not in remission. An elopement risk assessment showed a score of 4, and the assessment indicated that a score of 4 or greater required a care plan related to elopement risk. A progress note documented that the resident was on a civil commitment, and social services staff stated court documents were uploaded after they were received by e-fax. The social services designee acknowledged the resident was under civil commitment through May 21, 2026, with recommendations for continued psychiatric treatment because the resident was a significant danger to himself, chemically dependent, and not safe to live at home alone. Review of the care plan showed it lacked information or staff direction related to both elopement risk and civil commitment, and the DON acknowledged both focus areas should have been included. The facility’s elopement policy required a care plan addressing potential wandering or exiting the facility and measures to prevent elopement.
Inaccurate Elopement Risk Assessments
Penalty
Summary
The facility failed to accurately document elopement risk factors on assessments for 2 residents. One resident had an admission MDS showing moderate cognitive impairment and diagnoses including Wernicke's encephalopathy, alcoholic cirrhosis of the liver, and alcoholism not in remission. That resident's elopement risk assessment listed only ambulation/self-propelling a wheelchair and asking to go home, but it also documented a score of 4 without accurately reflecting the resident's prescribed quetiapine and cognitive deficits. The resident's care plan lacked information or staff direction related to elopement risk, and an RN later acknowledged the assessment was not completed accurately. The DON also stated the resident should not have had progress notes documented while on LOA. A second resident's admission MDS showed intact cognition and diagnoses including hepatic encephalopathy, cachexia, alcoholic cirrhosis with ascites, chronic hepatic failure, adult failure to thrive, depression, and alcohol abuse in remission. That resident's elopement risk assessment scored the resident as 1 based only on being ambulatory, but it did not include confusion from hepatic encephalopathy or the prescribed quetiapine, which would have increased the score to 3. The RN who completed the assessment acknowledged she did not usually review the diagnosis list and medication list when completing the assessment, but should have, and the DON acknowledged both residents' assessments were inaccurate and should have included cognitive deficits and antipsychotic medications.
Failure to Include Cervical Collar Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for one resident who was admitted with a cervical spine fracture and an Aspen cervical collar. The resident’s diagnoses included other displaced dens fracture, diabetes with diabetic nephropathy, depression, chronic pain, anxiety, need for assistance with personal care, and dorsopathy. The resident was cognitively intact, had no behaviors, and required moderate assistance with activities of daily living. The hospital discharge summary included directions that the collar remain on at all times unless otherwise indicated, that skin under the collar be cared for and documented every 8 hours, that neurological assessments be conducted after initial collar application and then every 8 hours and as needed, and that the collar pads be changed daily and as needed. The resident’s care plan addressed skin integrity and self-care deficits, but it did not include any interventions specific to the cervical collar or its management. The November TAR did not include treatment orders or related care interventions for the collar, changing or removing the collar, assessing the skin or neck under the collar, or when to notify a physician for concerns. Weekly skin inspections were documented, but one inspection did not specify whether the collar was removed to assess the skin, and another noted the resident declined a bed bath, shower, and skin inspection. During interview, the resident stated staff had not washed the skin underneath the collar and that the collar had not been removed to assess the site or change the padding, and she reported that it had been itchy all the time. The RN stated she had never removed the collar and that the skin assessment documented on the weekly skin inspection did not include assessment under the collar. When the collar was removed during observation with two staff assisting, the skin underneath was red but had no open areas. The DON stated collar management was done by assessment and changing it on shower day and said there should have been orders in the EHR, but no facility policy or procedure for braces or collars was provided.
Failure to Assess and Document Cervical Collar Skin Care
Penalty
Summary
The facility failed to properly assess and monitor the skin condition of a resident with a cervical collar for a cervical fracture. The resident was admitted with diagnoses including other displaced dens fracture, type II diabetes with diabetic nephropathy, depression, chronic pain, anxiety, need for assistance with personal care, and dorsopathy. The hospital discharge summary directed that the Aspen collar remain on at all times unless otherwise indicated, that skin under the collar be cared for and documented every 8 hours, that a neurological assessment be documented after initial collar application and then every 8 hours and as needed, and that the collar pads be changed daily and as needed. The resident’s baseline care plan did not include the hospital collar instructions, and the November TAR did not include treatment or care for the cervical collar, removal or changing of the collar, skin assessment under the collar, or guidance for when to notify a physician. The weekly skin inspection on 11/15/25 noted no new skin issues but did not specify whether the collar was removed to inspect the skin, and the 11/8/25 skin inspection documented that the resident declined a bed bath, shower, and skin inspection. During interview, the resident stated staff had not washed the skin underneath the collar, had not removed it to assess the site or change the padding, and that it had been itchy all the time. Staff interviews showed inconsistent understanding of collar care and documentation. An RN stated the order set should appear in the EHR and that skin under the collar would typically be checked during showers or when the collar was removed, but she had never removed the resident’s collar. A PT stated nurses should manage the collar and that skin should be washed daily with pads changed at least every shower day. When the collar was removed during observation, the skin underneath was red with no open areas. The RN manager stated residents with a cervical collar should have daily skin assessments documented in a progress note, and the DON stated collar care should include assessment and changing on shower day, but also noted the main issue was the lack of orders in the EHR. The facility did not provide a policy or procedure for braces or collars.
Failure to Protect Resident from Abuse Due to Inadequate Mental Health Intervention
Penalty
Summary
The facility failed to protect a resident from abuse when it did not adequately evaluate or address the effectiveness of interventions for another resident's mental health and substance use needs. One resident, with a history of substance abuse and recent methamphetamine use, exhibited escalating behavioral disturbances, including vandalism, aggression toward staff, and ultimately a physical assault on another resident. Despite multiple incidents indicating a change in mental status and behavior, including reports of auditory hallucinations, aggression, and erratic actions, the facility's documentation lacked evidence of reassessment or adjustment of care plan interventions to address these acute mental health concerns. The resident who committed the assault had a documented history of substance abuse and mental health diagnoses, including adjustment disorder and alcohol abuse. In the days leading up to the incident, this resident was observed engaging in disruptive and violent behaviors, such as letting air out of vehicle tires, scratching cars, and attempting to physically harm staff. The resident was also noted to have refused medications and was found to be under the influence of methamphetamines, as confirmed by hospital records. Despite these warning signs and hospital visits for psychiatric evaluation, the facility did not implement or document enhanced monitoring or effective interventions to mitigate the risk posed by this resident. The victim of the assault was a cognitively impaired resident with a history of traumatic brain injury and required supervision for daily activities. This resident was physically pushed over in his wheelchair by the other resident, who then attempted to further harm him before staff intervened. The victim expressed ongoing fear and emotional distress following the incident. The facility's records did not show consistent documentation of safety checks or targeted interventions for either resident in response to the escalating behaviors and the eventual assault.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of alcohol abuse, extreme trauma, and mental health disorders. The resident was assessed as cognitively intact with minimal depression and had a goal to return home. Although the resident declined in-house psychiatry services, the care plan did not address opportunities for autonomy, community connections, or support for cultural and religious practices. The care plan also lacked a thorough, person-centered description of the resident's distress and did not include measurable interventions or programs to assist the resident in achieving optimal mental and psychosocial functioning. The resident experienced a decline in mental health, which manifested in aggressive and abusive behaviors toward staff and another resident, as well as multiple incidents involving law enforcement and hospitalizations. Documentation showed that the resident was prescribed medications for mood and sleep, but non-pharmacological interventions such as redirection and one-to-one visits were not clearly defined in purpose or intent. The care plan did not specify the rationale for these interventions, and there was no evidence of reassessment or updates to the care plan following significant behavioral incidents, substance use, or psychiatric hospitalizations. Interviews with facility staff revealed a lack of awareness and action regarding the provision of chemical dependency treatment, trauma-informed care, or psychosocial therapies tailored to the resident's needs, especially considering language barriers and the resident's history of trauma and substance abuse. The social services director confirmed that no chemical dependency or therapeutic interventions were offered, and the director of nursing was unaware of any such services being provided. The facility was unable to provide a policy for treatment and/or services for mental and psychosocial concerns, and the medical record did not reflect that appropriate support, treatment, or services were provided to help the resident attain the highest practicable mental and psychosocial well-being.
Failure to Assess Self-Administration and Bedside Medication Orders
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications and failed to obtain orders for leaving medications at the bedside and/or self-administration for one resident reviewed for self-administration of medications. The resident was re-admitted to the facility on 7/30/25 and had diagnoses including end stage renal failure, fluid overload, conversion disorder with seizures, hypertension, cerebral infarction, pulmonary edema, and need for assistance with personal care. During observations, an albuterol inhaler with the resident's name on the label and a bottle of Ocean nasal spray with the resident's name on the label were seen on the bedside table. The medical record lacked a self-administration of medications assessment, an order to self-administer medications and/or leave medications at bedside, and an order for Ocean saline nasal spray. An RN stated the resident needed a medication self-administration assessment before medications could be kept at the bedside or self-administered, and the DON confirmed the resident did not have a self-administration order, lacked an order to leave medications at bedside, and had no order for Ocean nasal spray.
Missing Ombudsman Notification for Hospital Transfers
Penalty
Summary
The facility failed to ensure that written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 5 residents reviewed, R12 and R21, when they were transferred to the hospital. R12’s record showed a hospital transfer on 6/2/25 and progress notes indicated the resident was hospitalized from [DATE] to [DATE], but the medical record lacked evidence that a written notification of transfer was sent to the Ombudsman. R12’s face sheet listed diagnoses including a wound of the lower back and pelvis, major depressive disorder, paraplegia, pulmonary embolism, gunshot wound, neurogenic bladder, incontinence, septicemia, and neurogenic bowel. R21’s record showed the resident was hospitalized from [DATE] through 7/20/25 and then re-admitted to the facility on 7/30/25, but there was no documentation that the Ombudsman for long term care office was notified. R21’s face sheet listed diagnoses including end stage renal failure, fluid overload, conversion disorder with seizures, hypertension, cerebral infarction, pulmonary edema, and need for assistance with personal care. The administrator confirmed the previous social worker had not completed the Ombudsman notifications in June or July 2025, and the facility’s transfer/discharge policy stated that a copy of the notice is sent to the state long term care Ombudsman at the same time it is provided to the resident.
Medication Administration Documentation Did Not Match Ordered Form
Penalty
Summary
The facility failed to complete proper medication administration checks for one resident who had a significant change MDS documenting psychotic disorder and depression. The resident had a Moments Hospice order for lorazepam 0.5 mg by mouth every 4 hours as needed for terminal agitation, and the facility’s Order Summary Report also listed lorazepam oral tablet 0.5 mg by mouth every 4 hours as needed for terminal agitation. However, the facility narcotic book documented lorazepam liquid, 0.5 mL every 4 hours, for the same resident, with administrations recorded on 7/8 and 7/9. The medication record for the resident documented lorazepam oral tablet 0.5 mg was administered on 7/8/25 and 7/9/25, which did not match the narcotic book entry for liquid medication. During interview, RN-A stated she would review the original order if she had a question during medication administration and confirmed the medication record said oral tabs while the narcotic book said liquid medication for the same time and documentation. The DON stated staff were expected to complete the five rights of medication administration before giving a medication and to clarify with the pharmacy and update the medication record if there were changes, and confirmed that changing from tablets to liquid form would require a new order. The CP also confirmed that a new order was necessary if changing from tablet to liquid form. Facility policy stated a triple check of the five rights is recommended during administration and that the physician was to be contacted for a new order prior to changing from pill solid tablet to liquid dosage.
Dialysis Communication and Coordination Failure
Penalty
Summary
The facility failed to ensure coordination of care and communication between the facility and the dialysis center for a resident receiving hemodialysis. R21 had diagnoses including anemia, hypertension, renal insufficiency, renal failure, or ESRD, was receiving hemodialysis three days per week, and was cognitively intact with a BIMS score of 15. The physician orders required hemodialysis every Tuesday, Thursday, and Saturday, monitoring of the dialysis site for bleeding and fistula for bruit and thrill, completion of a post-dialysis vital signs check, completion of a dialysis communication form to accompany the resident to dialysis, and review of the post-dialysis treatment report for updates. Although the care plan included interventions for dialysis-related complications and sending a communication folder/form to each dialysis appointment, RN-A stated she did not routinely send a dialysis communication form unless there was a change since the previous appointment and had not sent one with R21 for that day’s dialysis. RN-A also stated that if the resident did not bring back a form from dialysis, she would not call for an update. The dialysis binder lacked completed communication forms for R21 for June, July, and August 2025, and the DON confirmed that although the EMR documented completion and review of the communication form, R21 had not had any dialysis communication forms completed since May 2025. The facility policy required ongoing communication and collaboration with the dialysis center and stated that if dialysis run information was not received upon return, staff would call the dialysis unit to obtain it.
Improper Disposal of Controlled Medications After Resident Discharge
Penalty
Summary
The facility failed to properly dispose of controlled medications for two residents after discharge. One resident’s MDS documented that the resident was discharged/deceased, and the resident’s order summary included lorazepam oral concentrate 2 mg/mL ordered for anxiety and restlessness. During a tour of the medication room, the ADON found the resident’s lorazepam stored in the refrigerated controlled-substance lock box, but the tracking page for that medication could not be located in the current narcotic book. The tracking was instead found in an unused book stored in a cupboard, and the last documented narcotic count in that book had been completed on a prior date. The ADON confirmed the resident was no longer at the facility and that tracking had not been completed since the book was retired from use. A second resident’s significant change MDS documented psychotic disorder and depression, and a progress note stated the resident died in the facility in the presence of a hospice nurse. The resident’s hospice order included lorazepam 0.5 mg by mouth every 4 hours as needed for terminal agitation. During the medication room tour, the ADON found this resident’s lorazepam in the refrigerated controlled-substance lock box as well. The ADON confirmed the resident was no longer in the facility and stated floor staff should have disposed of the medication. The DON stated controlled medications were counted at shift change or when medication cart or narcotic keys changed hands, and the consultant pharmacist stated medications should be disposed of or destroyed when a resident discharges or passes away. Facility policy required controlled substances to be disposed of by two licensed nurses and documented in a record book after discharge.
Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
Controlled refrigerated medications were not stored in a permanently affixed, separately locked compartment. During a tour of the medication room, the assistant director of nursing showed an unlocked medication refrigerator containing a small lockbox. The lockbox was removed from the refrigerator and unlocked, revealing 6 controlled medications inside. The assistant director of nursing confirmed the lockbox was not permanently affixed to the refrigerator and stated the facility had explored ways to attach it but had not yet found a solution. The director of nursing later confirmed the controlled refrigerated medications were kept in a lockbox inside the locked medication room, but the lockbox was not permanently affixed because the facility had not figured out how it wanted to secure it. The director of nursing stated the medications were double locked, but not in a permanently affixed compartment. The consultant pharmacist stated controlled substances should have been stored in a permanently affixed double lock compartment to prevent diversion, and noted the issue had been identified during a recent pharmacy audit. The facility policy dated August 2019 stated controlled substances requiring refrigeration are to be stored within a locked box in the refrigerator that must be attached to the inside of the refrigerator.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to perform proper hand hygiene during wound care for a resident with moderate cognitive impairment and moisture-associated skin wounds. The resident's care plan required enhanced barrier precautions and specified that staff should don and doff personal protective equipment (PPE) according to protocol when providing high-contact care. During the observed wound care procedure, the LPN repeatedly changed gloves without sanitizing her hands between glove changes, despite handling both clean and dirty tasks. The LPN acknowledged not knowing that hand hygiene was required between glove changes. The director of nursing (DON) observed the procedure and confirmed that the LPN did not follow the facility's wound care treatment procedure, which directed staff to complete hand hygiene after removing gloves and before donning another pair. The DON stated that the expectation was to sanitize hands between glove changes and to change gloves between clean and dirty care. The facility's policy, as well as the resident's care plan, required these infection prevention measures, but they were not followed during the observed wound care event.
Failure to Complete Annual Performance Review for Nursing Assistant
Penalty
Summary
The facility failed to complete an annual performance review for a nursing assistant who was hired in October 2023. Review of the personnel file showed no evidence that a performance evaluation had been conducted. During interviews, the nursing assistant confirmed that no evaluation had taken place since hire, and the DON acknowledged that the review was due but had not been completed. Additionally, the facility did not have a policy regarding performance reviews. This deficiency had the potential to affect all residents receiving care from this staff member.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a resident who complained of rough care by a nursing assistant was reported to the State Agency (SA) immediately, but no later than two hours after the suspicion was formed. The incident was initially brought to the facility's attention by local police, who informed the Social Services Director (SSD) that a report had already been filed with the Minnesota Abuse Reporting Center (MAARC) regarding the alleged rough handling of the resident, which resulted in pain to the resident's leg and abdomen. Despite being made aware of the allegation, the facility did not file a separate report with the SA as required by their Abuse Prohibition/Vulnerable Adult policy, which mandates reporting within two hours of suspicion. Interviews with facility staff, including the DON, registered nurse, nursing assistants, and social services designee, revealed inconsistent understanding of the reporting requirements, with some staff believing the timeframe was 24 hours and others unsure of the exact process. The DON confirmed that no report was filed by the facility, relying instead on the fact that another entity had already reported the incident. The facility's policy, however, clearly states that suspected abuse must be reported to the Office of Health Facility Complaints (OHFC) within two hours, a step that was not taken in this case.
Failure to Schedule Registered Nurse for Minimum Required Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of 8 consecutive hours a day, affecting all 35 residents. Review of the facility's daily staffing hours and staff schedules from February 1, 2024, to April 30, 2024, revealed that there was no RN scheduled on multiple dates. Interviews with the staffing coordinator, Licensed Practical Nurses (LPNs), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the administrator confirmed the absence of RNs on these dates. The ADON and DON, who are RNs, were not included in the regular schedule and were only on call during weekends. The facility also had a Manager on Duty (MOD) on weekends, but not all MODs were RNs, and they were only required to work 4 hours a day. The staffing coordinator admitted that the facility did not have any RNs on staff except for the ADON, DON, and occasional agency/pool nurses. The administrator acknowledged the difficulty in hiring RNs due to better pay in hospitals and mentioned that they had recently hired two RNs who were still in training. The facility did not have a policy on staffing, and the lack of RNs on the floor led to situations where LPNs had to call the on-call physician or the ADON/DON for assistance. This deficiency had the potential to affect the quality of care provided to all residents in the facility.
Failure to Provide Ordered Podiatry Care
Penalty
Summary
The facility failed to provide ordered podiatry care for a resident (R23) who required assistance with personal hygiene and had multiple medical conditions, including heart failure, respiratory failure, hypertension, morbid obesity, and a fungal infection of the nail. Despite a nurse practitioner's order for a podiatry consult due to overgrown toenails, there was no documentation of a podiatry visit from the time of the order until the survey. Observations revealed that R23's toenails were long, torn, yellow, thickened, and dirty, indicating a lack of proper foot care. Interviews with staff confirmed that nail care was not consistently provided, and there was confusion about whether transitional care unit residents could receive podiatry services. The nursing assistant and health unit coordinator (HUC) were unsure when R23's nail care was last performed, and the HUC admitted that R23 had not been seen by a podiatrist historically. The licensed practical nurse (LPN) confirmed that R23's toenails were too thick to be cut with regular clippers and required podiatry intervention. The director of nursing (DON) explained that ancillary services like podiatry were discussed during care conferences, but there was a misunderstanding about the eligibility of transitional care unit residents for podiatry services. This misunderstanding led to the failure to initiate the podiatry order for R23, resulting in inadequate foot care for the resident.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure prescribed medications were available for a resident (R23) who was awaiting a new medication. R23, who had intact cognition and required extensive assistance with personal hygiene and bathing, had a history of heart failure, respiratory failure, hypertension, and morbid obesity. The resident's care plan identified an alteration in skin integrity due to self-inflicted skin tears, and a provider order dated 4/25/24 prescribed N-acetyl-cysteine to address skin picking. However, the medication was not administered from 4/26/24 through 5/2/24, resulting in 15 missed doses. Interviews with staff revealed that the medication was considered a house stock item, and the business office manager (BOM) was responsible for ordering it. The pharmacy technician confirmed that the facility had not completed the required house stock medication form, leading to the medication not being sent out. Further interviews indicated that the BOM was unsure if the medication had been ordered, and the registered nurse (RN) acknowledged that the missing medication should have been addressed sooner. The director of nursing (DON) stated that if the pharmacy could not provide a house stock medication, the facility staff should have purchased it themselves, ideally on the same day or within two days. The facility's assessment identified that they offered medication administration services and had vendors in place to provide necessary supplies and services, yet the medication for R23 was not obtained in a timely manner.
Failure to Implement Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure the timely implementation of pharmacist recommendations for a resident reviewed for unnecessary medications. The resident's annual Minimum Data Set (MDS) indicated diagnoses including coronary artery disease, hypertension, and hyperlipidemia, and the resident was on antiplatelet medication. The care plan initiated lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. The pharmacist's medication regimen review (MRR) repeatedly recommended a lipid panel to evaluate the ongoing use of Fenofibrate, but these recommendations were not addressed until several months later. The Director of Nursing (DON) confirmed that the lipid panel order was missed for two consecutive months and was only ordered in the third month, with the results showing elevated triglyceride levels. During an interview, the DON stated that the facility's process involved completing pharmacy MRRs at the beginning of the month and providing copies to the provider and the facility. The facility would also fax the MRRs to the provider and track the provider's response. However, the DON was unable to locate follow-up documentation for the pharmacy MRR for the initial months and confirmed that the lipid panel order was missed. The facility policy on pharmacy MRRs was requested but not received, indicating a lapse in the facility's adherence to its own procedures and policies regarding medication regimen reviews and follow-up actions.
Failure to Ensure Proper Use and Documentation of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure an antipsychotic medication was not started without adequate medical justification and that a discussion of risks, benefits, and potential side effects was understood by the resident, representative, or family for one resident. Specifically, a resident with severe cognitive impairment was prescribed Seroquel for insomnia without proper documentation of medical justification or a discussion of the medication's risks and benefits. The resident's care plan lacked focus areas, goals, or interventions related to insomnia or antipsychotic medications, and there was no tracking of insomnia behaviors or non-pharmacological interventions to manage insomnia behaviors in the medical record. Additionally, the facility failed to include individualized approaches for care, including behavior tracking and non-pharmacological interventions for two residents. One resident's medical record lacked documentation of behaviors occurring before the administration of PRN antipsychotic medication and non-pharmacological interventions attempted prior to administration. The resident received Seroquel PRN for agitation related to paranoid personality disorder, but the medical record did not document the necessary behavior tracking or non-pharmacological interventions. Interviews with staff revealed a lack of awareness regarding regulations related to antipsychotic administration and the importance of behavior tracking and non-pharmacological interventions. The facility's policy on psychotropic medication use was not followed, as it required informed consent, behavior tracking, and non-pharmacological interventions to be documented. The consultant pharmacist confirmed that the medical records were lacking appropriate justification for the use of antipsychotic medications, non-pharmacological interventions, behavior tracking, and evaluation by the provider after 14 days of using a PRN antipsychotic.
Failure to Offer Pneumococcal Vaccine as per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one of five residents was offered or received the pneumococcal vaccine in accordance with CDC recommendations. The resident, who had a history of non-Alzheimer's dementia, asthma, chronic obstructive pulmonary disease, and chronic lung disease, had documentation indicating that their pneumococcal vaccinations were up to date. However, upon review, it was found that the resident had received Prevnar 23 in 2010 and Prevnar 13 in 2015, but there was no evidence of a shared clinical decision-making discussion regarding additional pneumococcal vaccinations as per CDC guidelines. During an interview, the assistant director of nursing (ADON) stated that they had assumed the resident did not need additional pneumococcal vaccinations based on the current documentation. The ADON clarified that the facility and provider had not conducted a clinical decision-making discussion with the resident. The facility's policy indicated that all residents should be assessed for immunization status within five days of admission and offered the vaccine within 30 days if indicated. However, this process was not followed for the resident in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,035 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fridley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victory Health & Rehabilitation Center | 1.9 mi | ★★★★★ | 15 | 0 |
| Crest View Lutheran Home | 2.6 mi | ★★★★★ | 2 | 0 |
| Benedictine Health Center Innsbruck | 2.6 mi | ★★★★★ | 17 | 0 |
| Bywood East Health Care | 3.2 mi | ★★★★★ | 26 | 3 |
| Maranatha Care Center | 3.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.