The Estates At Fridley Llc

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

cervical collar should be performed and documented every 8 hours. Conduct a neurological assessment and document after initial collar application, then every 8 hours (and as needed), or per provider orders.-Providing skin care to a patient in a cervical collar:1. Place the head of the bed flat.2. A second caregiver will secure the head and neck to maintain alignment.3. A third caregiver will stand by to assist with log rolling turns.4. Note neurological assessment of extremities. Remove the front portion of the collar and assess the visible skin condition carefully. Assess for areas of redness, rashes or skin breakdown.5.

Cleanse face and neck with soap and water. Gently dry skin thoroughly.6. The pads on an Aspen collar should be changed daily and as needed. During an interview on 11/19/25 at 12:14 p.m., Resident R2 stated staff have not washed the skin underneath her C-collar. Her C-collar was supposed to be on 24/7, she had been there for almost two weeks and staff have not removed the collar to assess the site or change the padding.

It had been itchy all the time. Tearfully, she stated I understand this is scary and it's scary for me too, but I need help with it.During an interview on 11/19/25 at 12:39 p.m., registered nurse (RN)-A stated she was Resident R2's nurse for the day. When a new resident is admitted with a brace, the admissions staff will enter the documentation into the electronic health record (EHR). Information about brace should be in the order set.

Anytime the brace comes off and when residents have showers it should be documented. The opportunity to check their skin underneath would be during showers and if the brace is taken off at night or if they complain of discomfort. RN-A had worked with Resident R2 several times and had never removed her C-collar. RN-A documented the skin assessment from 11/15/25 but didn't assess the skin underneath the collar and stated

the nursing assistant who gave the bed bath also wouldn't have removed the collar.During on observation

on 11/19/25 at 2:21 p.m., RN-A entered Resident R2's room at the request of the surveyor to remove the C-collar and assess the skin. Resident R2 reminded RN-A that removing the C-collar r required two staff. RN-A called in a nursing assistant (NA)-A to assist, NA-A held Resident R2's head and neck straight while RN-A removed the C-collar. The skin underneath was red but had no open areas. After RN-A and NA-A left the room, Resident R2 reported staff had just come in before the surveyor to remove the C-collar and change the pads.During an

interview on 11/19/25 at 2:52 p.m., Resident R2's nurse manager RN-B stated admission staff would put in the C-collar orders when a resident comes from the hospital and nurses on the floor would double check the orders.During an interview on 11/19/25 at 2:52 p.m., the director of nursing (DON) stated C-collar are managed by doing an assessment and changing it on shower day. When asked if interventions for managing the C-collar should be in the care plan, the DON did not answer but stated the nurse manager is responsible for the care plan. She stated there should be orders in the order set for managing the C-collar.

When asked what areas for improvement there were for managing Resident R2's C collar, the DON only mentioned that there should have been orders in the EHR.The neurosurgery clinic that was managing Resident R2's cervical fracture did not respond to the interview request.A facility policy or procedure pertaining to braces or collars was requested but not received.

Event ID:

Facility ID:

If continuation sheet

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

11/19/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

should be managing the collar. Everyday the skin should be washed as there could be a lot of sweating underneath the C collar. Pads should be changed at least every shower day. All care for the C-collar should be documented. PT-A was not aware of any concerns with managing the care of Resident R2's C-collar.During on

observation on 11/19/25 at 2:21 p.m., RN-A entered Resident R2's room at the request of the surveyor to remove the C-collar and assess the skin. Resident R2 reminded RN-A that removing the C-collar required two staff. RN-A called

in a nursing assistant (NA)-A to assist, NA-A held Resident R2's head and neck straight while RN-A removed the C-collar. The skin underneath was red but had no open areas. After RN-A and NA-A left the room, Resident R2 reported staff had just come in before the surveyor to remove the C-collar and change the pads.During an

interview on 11/19/25 at 2:52 p.m., Resident R2's nurse manager RN-B stated residents who have a C-collar should have daily skin assessments and should be documented in a progress note. The pads should be changed weekly and as needed. admission staff would put in the C-collar orders when a resident comes from the hospital and nurses on the floor would double check the orders. RN-B stated Resident R2 refused the weekly skin check at least twice but was unable to provide supporting documentation for both refusals.During an

interview on 11/19/25 at 2:52 p.m., the director of nursing (DON) stated C-collar are managed by doing an assessment and changing it on shower day. The DON went on to explain that Resident R2 had been refusing a lot of cares such as getting out of bed, eating and seeing the physician. When documenting in the skin assessment form, nurses should remove the C-collar to assess and document the findings. When asked what areas for improvement there were for managing Resident R2's C-collar, the DON only mentioned that there should have been orders in the EHR.The neurosurgery clinic that was managing Resident R2's cervical fracture did not respond to the interview request.A facility policy or procedure pertaining to braces or collars was requested but not received.

Event ID:

Facility ID:

If continuation sheet