The Estates At Fridley Llc

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

should have been. He was not certain whether the staff had started monitoring Resident R1 for signs and symptoms of substance abuse or not. He believed the staff implemented 15-minute safety checks on Resident R1 after he assaulted RN-A and was found to have methamphetamines in his system. The administrator stated there was an all staff training a few weeks prior on de-escalation. The training was their annual training and not regarding any specific resident for any specific reason. The Administrator stated he spoke with Resident R2 daily following the assault and each day Resident R2 was emotionally improving with his fears. Resident R2 had been moved to a new room and was happy with his roommate and Resident R1 apologized to him. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy with a revision date of 4/2025 indicated the purse was to protect residents against abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse.Prevention:1. Each referral received is assessed through the pre-admission medical screening process for susceptibility to abuse by individuals and their risk of abusing others. This assessment includes risk of self-abuse. Plans are developed and measures taken to minimize risks.

Ongoing assessments are completed with each quarterly care conference.2. The Interdisciplinary Care Plan Team reviews residents requiring behavioral interventions at least quarterly and/or during Target Behavior meetings to develop individual behavior plans.3. Residents and families are informed of the Residents' Rights and Grievance procedure upon admission to the facility and annually through Resident Council.4. Department Directors are updated regarding falls and resident incidents and are responsible for ongoing supervision of subordinates regarding abuse prevention.5. Identification and analysis of physical environmental factors that may make abuse and neglect more likely to occur is completed and reviewed by

the QAPI committee.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Fridley LLC

5700 East River Road Fridley, MN 55432

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

himself to where he will be the rest of his life. He stated he drinks alcohol almost daily and refused to answer how often he used illegal drugs. Upon interview on 10/27/25 at 1:01 p.m. the director of social services (SW)-A stated Resident R1 started having behaviors after an unplanned leave of absence on 10/10/25 10/11/25. On 10/13/25 Resident R1 was letting air out of the tires of staff cars in the parking lot. On 10/15/25 Resident R1 physically assaulted registered nurse (RN)-A. On 10/15/25 Resident R1 was discharged from the emergency department with a lab result showing Resident R1 tested positive for methamphetamines. On 10/21/25 Resident R1 pushed over Resident R2 unprovoked in his room and was assaultive to staff. The paramedics took Resident R2 to the hospital and he was there until 10/24/25. SW-A stated every resident gets offered in-house therapy visits. She denied offering Resident R1 chemical dependency inpatient or outpatient or any therapeutic interventions while he at the facility due to his age, English as a second language, trauma from being found frost bitten unconscious and bilateral below the knee amputations. She was not aware of any treatment offered to Resident R1 after his behavior changed and he was found to have used methamphetamines while being at the facility. SW-A was not aware if the facility staff had knowledge of how to support Resident R1 when he was distressed. Upon interview on 10/27/25 at 2:14 p.m. the DON stated she was aware that residents were officed in-house psychiatry upon admission and it was their right to refuse it. She stated she thought SW-A had reached out to the in-house provider to complete a diagnostic assessment on Resident R1 following the incident on 10/15/25 when Resident R1 assaulted staff and was found to have methamphetamines in his system. The DON denied knowledge of Resident R1 being offered chemical dependent or other treatment outside the facility during his stay. A policy for treatment and/or services for mental and psychosocial concerns was requested however none was provided.

Event ID:

Facility ID:

If continuation sheet