The Estates at Fridley LLC

In the surveyor’s words

From the most serious findings on record at The Estates at Fridley LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Aug 12, 2022

  Based on interview and document review, the facility failed to comprehensively assess and modify treatments and interventions to prevent further development of pressure ulcers and worsening of an existing pressure ulcer for 1 of 1 resident (R4). This resulted in an immediate jeopardy (IJ) situation for R4 who had deep tissue injury (DTI) (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) and developed a new Stage III pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue (the tissue below the skin that may extend down to, but not through, underlying fascia). The IJ began on 7/10/22, at 10:04 p.m. […]

• Actual harm, isolatedF600Oct 27, 2025

  Based 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. […]

• Actual harm, isolatedF684Oct 25, 2022

  Based on interview and document review the facility failed to follow physician orders to relieve [CONDITION(S)] and for [CONDITION(S)] stent removal, failed to comprehensively assess intake and output, and failed to consistently monitor for signs and symptoms of urinary tract infection for 1 of 1 resident (R1) who had history of urinary [CONDITION(S)]. The deficient practice resulted in harm when R1 was readmitted to the hospital for urinary [CONDITION(S)]. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, MDS indicated R1 required extensive assist by two staff for toileting. R1's pain care plan dated 5/19/2021, identified R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF711Oct 12, 2022

  Based on interview and document review, the facility failed to ensure the provider performed a comprehensive review of medications at each provider visit for 1 of 1 residents (R4) reviewed for provider visits. The facility failure to ensure the attending physician provided a comprehensive review of R4's medications resulted in R4 not receiving orders for and being administered [MEDICATION(S)] (anti-[CONDITION(S)] medication) for a period of 6 months which resulted in harm when R4 experienced breakthrough seizures at the facility and was hospitalized for seizures. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired. […]

• Actual harm, isolatedF600Jan 5, 2022

  Based on interview and document review, the facility failed to ensure residents were free from sexual abuse for 1 of 2 residents (R2) reviewed for sexual abuse. This resulted in psychosocial harm for R2 when she was sexually abused by R1. Findings include: A nursing home incident report (NHIR) dated 12/29/21, at 4:00 p.m. indicated R1 was observed by nursing assistant (NA)-A in R2's room with his hands down R2's gown rubbing her chest and rubbing R2's inner thighs outside of her incontinent brief. R2's Face Sheet printed 1/5/22, indicated R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]