The Estates At Fridley Llc

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 (Resident R1) reviewed. Findings include: Resident R1's admission Minimum Data Set (MDS) dated [DATE REDACTED] indicated moderate cognitive impairment and diagnoses that included Wernicke's encephalopathy (an acute neurological disorder with symptoms that include difficulty moving and confusion), alcoholic cirrhosis (liver damage) of the liver, and alcoholism not in remission. Resident R1's Elopement Risk assessment dated [DATE REDACTED], indicated a score of 4. The assessment indicated an elopement risk based on the nurse's assessment. The assessment further indicated with a risk score of 4 or greater, the facility should develop a care plan related to elopement risk. Resident R1's progress note dated 9/19/25 at 9:03 a.m., indicated Resident R1 was on a civil commitment. Resident R1's care plan reviewed on 10/3/25 lacked information or staff direction related to Resident R1's elopement risk and civil commitment. During an interview on 10/1/25 at 10:52 a.m., social services designee (SSD)-A acknowledged Resident R1 was on a civil commitment and indicated she uploaded court documents on 9/25/25 when she received them by e-fax. The SSD-A stated Resident R1's commitment was through May 21, 2026, and the recommendations in the commitment were for Resident R1 to continue psychiatric treatment because Resident R1 was a significant danger to himself, was chemically dependent, and not safe to live at home alone. The SSD-A acknowledged Resident R1 did not have a care plan related to the commitment but should have. During an interview

on 10/1/25 at 11:42 a.m., registered nurse (RN)-A stated Resident R1 did not have care plan interventions related to elopement or civil commitment, but should have, and further stated it was not her job to develop the care plan. During an interview on 10/1/25 at 2:30 p.m., the director of nursing (DON) acknowledged Resident R1's care plan lacked focus areas for elopement and civil commitment, but both should have been included in Resident R1's care plan. The DON stated the care plan was used to direct staff on how to care for the resident, and staff would not have known their responsibilities for either focus area. The Elopement Policy dated 6/23, indicated upon admission, each resident was assessed to establish elopement risk. Documentation should include a care plan that addressed potential to wander or exit the facility and measures taken to prevent elopement. A policy for civil commitment was requested and not provided.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/26/2025

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)

Federal health inspectors cited The Estates at Fridley LLC in FRIDLEY, MN for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-11-26.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of The Estates at Fridley LLC.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-28.