Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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 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 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.
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 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.
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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.
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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 | — | 21 | 1 |
| Maranatha Care Center | 3.6 mi | — | 3 | 0 |
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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 August 2026) and official state health department websites.