The Estates at Fridley LLC

Inspectors wroteBased on observation, interview, and document review, the facility failed to identify alternatives prior to installing or using grab bars (bars installed at the head of the bed for a resident to hold onto for bed mobility or transfers), ensure grab bars were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of grab bars for 1 of 3 residents (R1) who was observed to have grab bars on their bed. R1's diagnoses list dated 3/27/26 included spastic hemiplegia (stiff, weak muscles and involuntary movements on one side of the body) affecting left side and muscle weakness. R1's admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairmentDuring an observation and interview on 3/27/2026 at 12:25 p.m., R1 was observed in her room sitting in a power chair. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 49 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive care plan was updated to ensure elopement risk and civil commitment were identified, and appropriate interventions were developed for 1 of 3 residents (R1) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to accurately document risk factors on an elopement assessment for 2 of 3 residents (R1, R3).

Inspectors wroteBased on interview, observation and document review, the facility failed to develop a baseline care plan for 1 of 4 (R2) residents reviewed for care plans. R2 had a cervical fracture and cervical collar but did not have relevant interventions in the care plan for the management of the collar.

Inspectors wroteBased on interview, observation and document review, the facility failed to properly assess and monitor skin conditions for 1 of 4 (R2) residents reviewed for medical braces and quality of care. R2 had a cervical collar (C-collar) for a cervical fracture and the facility failed to document orders, complete skin assessments, assess the site and change the brace padding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 3 residents (R2) reviewed when the facility did not evaluate the effectiveness of R1's interventions for mental health needs. R1 entered R2's room and physically pushed him over backwards in his wheelchair, then attempted to throw the wheelchair at R2 before staff intervened. R1 displayed an outward change in condition on 10/13/25, went to the hospital on [DATE], and R1 called the police on 10/21/25 prior to the incident with R2. R1 had exhibited drug induced psychosis from recreational methamphetamine use in days leading up to the abuse. R2 was fearful of living with R1 in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and/or services were provided to 1 of 3 residents (R1) reviewed for mental health needs. R1 was assessed with a history of alcohol abuse, extreme trauma, and mental health disorders with limited interventions. R1's mental health declined resulting in abuse towards staff and a resident (R2), calls to the police, and hospitalizations.

Inspectors wroteBased on observation, interview and record review the facility failed to assess residents for the ability to self-administer medications, or obtain orders for leaving medications at bedside and/or self-administration for 1 of 1 (R21) residents reviewed for self-administration of medications.

Inspectors wroteBased on record review, and interview the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 2 of 5 (R12, R21) upon transfer to the hospital.

Inspectors wroteBased on observation, interview and document review, the facility failed to complete proper checks for 1 of 1 residents (R58) reviewed for medication administration documentation. R58's significant change MDS dated [DATE], included diagnosis of psychotic disorder and depression. R58's Moments Hospice order dated 6/7/25, included an order for lorazepam 0.5 mg by mouth every 4 hours as needed for terminal agitation (restlessness that occurs close to death). R58's Order Summary Report dated 8/6/25, included an order for lorazepam oral tablet 0.5 milligrams (mg) by mouth every 4 hours as needed for terminal agitation. Facility narcotic book included an entry for R58 for lorazepam liquid give 0.5 milliliters (mL) every 4 hours. Administrations were documented for 7/8 and 7/9. Medication record for R58 included administration for lorazepam oral tab 0.5 mg was administered on 7/8/25 and 7/9/25. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure coordination of care and communication between the facility and the dialysis center for 1 of 1 residents (R21) who received hemodialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly dispose of controlled medication for 2 of 2 residents (R57, R58) reviewed for disposal of medications after discharge. R57's death in facility minimum data set (MDS) dated [DATE], included R57 was discharged /deceased on [DATE]. R57's Order Summary Report printed [DATE], included an order for lorazepam oral concentrate 2 mg/ml (a medication give for anxiety) give 0.25 milliliters (mL) by mouth every 2 hours as needed for restlessness and anxiety AND give 0.25 mL by mouth every 4 hours for restlessness and anxiety. During tour of medication room on [DATE] at 1:50 p.m., assistant director of nursing (ADON) opened lock box used to store controlled substances requiring refrigeration. Lock box contained a box containing a bottle with a label that identified it as lorazepam 2mg/ml for R57. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to properly store controlled substances in 1 of 1 medication rooms reviewed for medication storage. During tour of medication room on 8/6/25 at 1:50 p.m., assistant director of nursing (ADON) showed the unlocked medication refrigerator with small unaffixed lockbox. ADON removed the lockbox from the refrigerator and unlocked it to show 6 controlled medications in the lock box. During interview on 8/6/25 at 1:50 p.m., ADON confirmed the lockbox was not permanently affixed to the refrigerator. ADON stated the facility had explored options to attach the lock box but had not yet found a solution. ADON described the box as similar to the size of an iPad and about 4 inches thick. ADON confirmed the whole box could be removed from the medication room. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene was performed when providing wound care for 1 of 3 residents (R2) reviewed for pressure ulcer care.

Inspectors wroteBased on interview and document review, the facility failed to ensure annual performance reviews were completed for 1 of 1 nursing assistants (NA-A) whose personnel files were reviewed. This deficient practice had potential to affect all residents who currently resided in the nursing home and who could receive care from this staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential abuse for 1 of 1 resident (R1) who complained of rough care by staff, was reported immediately but no later than 2 hours to the State Agency (SA).

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of 8 consecutive hours a day. This had the potential to affect all 35 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide ordered podiatry care for 1 of 1 resident (R23) reviewed for foot care.

Inspectors wroteBased on interview and document review, the facility failed to ensure prescribed medications were available for 1 of 1 resident (R23) who was awaiting a new medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the pharmacist recommendations were implemented timely for 1 of 5 residents (R9) reviewed for unnecessary medications. Findings Include: R9's annual Minimum Data Set (MDS) indicated R9's diagnosis included coronary artery disease, hypertension, hyperlipidemia and was on antiplatelet medication. R9's care plan initiated 2/16/23, lacked documentation for coronary artery disease and hyperlipidemia goals or interventions. R9's physician orders dated 2/16/23, indicated rosuvastatin calcium oral tablet, give 10 mg by mouth at bedtime for hyperlipidemia. R9's pharmacy medication regimen review (MRR) were as follows: -3/6/24, pharmacy MRR indicated, note: [...]

Inspectors wroteBased on interview and document review, 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 1 of 1 resident (R30) reviewed who had a newly prescribed antipsychotic. In addition, the facility failed to include individualized approaches for care, including behavior tracking and non-pharmacological interventions for 2 of 4 residents (R30 and R89), and failed to ensure as needed (PRN) antipsychotic medication was not used longer than 14 days without the resident being directly evaluated by the prescriber for 1 of 2 residents (R89) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R9) was offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 44 residents who resided at the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys in regards infection control and self-administration of medications (SAM) which were also identified during this survey. This had the potential to effect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to remove facial hair and maintain dignity for 1 of 3 residents (R4) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess and determine safety for self-administration of medications (SAM) for 2 of 2 residents (R34 and R243) whom were observed to have medications in their rooms.

Inspectors wroteBased on observation, interview, and document review, the facility failed to timely follow up on a resident requested medication change for 1 of 2 residents (R17) reviewed for choices.

Inspectors wroteBased on observation, interview and document review, the facility failed to revise care plan interventions with recommended behavioral approaches for 1 of 1 residents (R29) reviewed for mood and behavior.

Inspectors wroteBased on interview and document review, the facility failed to ensure pharmacy recommendations were addressed for 1 of 1 resident (R4) reviewed for antipsychotic medication side effects.

Inspectors wroteBased on observation, interview, and document review, the facility failed to timely arrange for an ordered urology examination 1 of 1 resident (R29) reviewed who required diagnostics services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) appropriately for 1 of 2 residents (R31) who was on transmission based precautions (TBP).

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R2 and R35) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to provide the COVID-19 vaccination timely to 1 of 1 resident (R37) whom requested to be vaccinated.