The Estates at Fridley: Cervical Collar Neglect - MN
By the time a state surveyor arrived on November 19, 2025, the woman, identified in inspection records only as R2, was itching constantly. When she described what had been happening, she was tearful.
"I understand this is scary and it's scary for me too," she told the surveyor. "But I need help with it."
The collar was an Aspen cervical collar, the kind used to immobilize the neck after a fracture. The protocol for managing one is specific: skin care underneath the collar should happen every eight hours, neurological assessments should follow the same schedule, and the foam pads built into the collar should be changed daily. Removing it requires two staff members, with one holding the patient's head and neck in alignment while the other works the collar free.
None of that had happened. Not once in nearly two weeks.
The nurse assigned to R2 that day, identified as RN-A, told the surveyor she had worked with R2 multiple times and had never removed the collar. She had documented a skin assessment on November 15, but she acknowledged she had not assessed the skin underneath the collar during that assessment. She said the nursing assistant who had given R2 a bed bath also would not have removed it.
The surveyor asked RN-A to remove the collar and check the skin while she was present. RN-A called in a nursing assistant to hold R2's head steady, and together they removed the collar. The skin underneath was red. There were no open wounds, but the redness was there, visible evidence of what two weeks of uninterrupted pressure and moisture will do.
After RN-A and the nursing assistant left the room, R2 told the surveyor something else: staff had come in just before the surveyor's visit to remove the collar and change the pads.
The director of nursing told the surveyor that cervical collars are managed by doing an assessment and changing the collar on shower days. When the surveyor asked whether interventions for managing R2's collar should have been written into her care plan, the director did not answer. She said the nurse manager was responsible for the care plan. She said there should have been orders in the electronic health record.
When the surveyor pressed her on what areas needed improvement in how R2's collar had been managed, the director of nursing mentioned only that orders should have been in the system.
That was the full extent of her answer.
The nurse manager, RN-B, told the surveyor that admission staff enter cervical collar orders into the electronic health record when a resident arrives from the hospital, and that floor nurses are supposed to double-check those orders. How the orders had failed to produce any actual collar care for R2 over nearly two weeks was not explained.
The surveyor requested a facility policy or procedure covering braces and collars. None was provided.
The neurosurgery clinic managing R2's cervical fracture did not respond to the surveyor's interview request.
R2 came to The Estates at Fridley from a hospital, already wearing the collar, already managing the fear that comes with a broken neck. She understood the stakes. She said so herself, sitting in that room, itching, trying to explain to a surveyor what two weeks without basic care had felt like. She was not asking for much. She was asking someone to do what the collar's own instructions require.
The inspection was completed November 19, 2025. The redness under R2's collar was still there when the surveyor left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Estates At Fridley LLC from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Estates at Fridley LLC in FRIDLEY, MN was cited for neglect violations during a health inspection on November 19, 2025.
By the time a state surveyor arrived on November 19, 2025, the woman, identified in inspection records only as R2, was itching constantly.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.