Inspection Reports for
Colleens Caring Hands Inc
2525 Bemidji Ave N, Bemidji, MN 56601, MN, 56601
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
57 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1362% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Follow-Up
Census: 10
Capacity: 10
Deficiencies: 57
Date: Oct 26, 2023
Visit Reason
Follow-up survey to determine if orders from the October 26, 2023 survey were corrected.
Findings
The facility was found to be in substantial compliance with previous orders. However, prior surveys identified multiple deficiencies including staffing plan issues, licensing violations, emergency preparedness plan deficiencies, contract content omissions, medication management issues, fire safety plan deficiencies, and privacy concerns related to electronic monitoring.
Deficiencies (57)
Failed to employ a licensed assisted living director (LALD).
Failed to develop and implement a staffing plan to meet residents' needs and failed to post staffing schedule.
Failed to develop a comprehensive emergency preparedness plan with all required elements.
Failed to maintain fire safety and evacuation plan with required elements including employee training and evacuation drills.
Failed to include required content in resident contracts including facility identification number and contract terms.
Failed to include required contract content related to medical assistance waivers and housing support program.
Failed to include required notice and opportunity for residents to designate a representative.
Failed to conduct background study for one employee prior to providing care.
Failed to conduct resident reassessment following change of condition (fall with fracture).
Failed to store medications according to manufacturer instructions and maintain medication refrigerator temperature within acceptable range.
Failed to label time sensitive medications with date opened and expiration date.
Failed to maintain medication security and accountability for controlled substances.
Failed to conduct annual medication management reassessment for resident.
Failed to maintain current individualized medication management plan including storage, monitoring, and documentation requirements.
Failed to document medication administration as prescribed and failed to document reasons for missed medications.
Failed to develop and maintain individualized treatment or therapy management plan with required content and annual review.
Failed to document treatment administration including date, time, and signature.
Failed to renew prescriptions and treatment orders at least every 12 months.
Failed to provide interconnected smoke alarms in dwelling units.
Failed to install and maintain portable fire extinguishers within required travel distance.
Failed to maintain physical environment in good repair including missing light cover, holes in ceiling tiles, storage in means of egress, improper door hardware, and unsecured water heater draft hood.
Failed to maintain fire safety and evacuation plan with required elements and training.
Failed to post grievance procedure with required contact information.
Failed to develop and implement individual abuse prevention plan for resident at risk of wandering/elopement with unsecured exit door.
Failed to post 911 emergency number in common areas and near telephones.
Failed to complete two-step tuberculosis screening for employee.
Failed to ensure background study was completed prior to employment for one employee.
Failed to provide medication management policies and procedures under supervision of licensed professional.
Failed to ensure medication security and accountability for controlled substances.
Failed to conduct annual medication management reassessment.
Failed to maintain individualized medication management plan with required content and annual update.
Failed to document medication administration as prescribed and document reasons for missed doses.
Failed to renew treatment orders annually.
Failed to ensure medications stored at proper temperatures per manufacturer instructions.
Failed to keep prescription medications in original container with legible label including expiration date.
Failed to ensure resident contracts included all required content including facility identification number, contract terms, complaint resolution process, and transfer policies.
Failed to offer residents opportunity to designate a representative in writing with required notice.
Failed to obtain written consent for electronic monitoring for two residents.
Failed to ensure licensee is legally responsible for management, control, and operation of the facility due to presence of apartments in same building.
Failed to ensure resident records included discharge summary for discharged resident.
Failed to ensure sufficient staffing to meet scheduled and unscheduled needs of residents including residents requiring two-person assist for transfers.
Failed to provide food prepared and served according to Minnesota Food Code.
Failed to post weekly menu at least one week in advance and make available to residents.
Failed to post grievance procedure with required contact information including ombudsman offices and email contact for grievance representative.
Failed to maintain fire safety and evacuation plan with required elements including employee training and evacuation drills.
Failed to maintain interconnected smoke alarms in dwelling units.
Failed to install and maintain portable fire extinguishers within required travel distance.
Failed to maintain physical environment in good repair including missing light cover, holes in ceiling tiles, storage in means of egress, improper door hardware, unsecured water heater draft hood, and open electrical wiring box.
Failed to ensure background study was conducted prior to staff providing services.
Failed to conduct direct supervision of staff performing delegated tasks within 30 days of hire.
Failed to update service plan to include current treatments and therapies.
Failed to document treatment administration including date, time, and signature.
Failed to renew prescriptions and treatment orders at least every 12 months.
Failed to ensure oxygen therapy treatment orders were renewed annually.
Failed to conduct annual medication management reassessment.
Failed to ensure care and services were provided according to accepted health care standards including safe use of hospital bedrails and safe storage of chemicals and oxygen.
Failed to ensure resident privacy with electronic monitoring devices by placing monitors in public areas and failing to obtain written consent.
Report Facts
Deficiencies cited: 47
Fine amount: 3000
Residents present: 10
Licensed capacity: 10
Medication refrigerator temperature: 46
Medication refrigerator temperature: 34
Bedrail measurement: 2.75
Bedrail measurement: 9.5
Bedrail gap: 1.5
Bedrail gap: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ULP-F | Unlicensed Personnel | Failed background study prior to employment, failed direct supervision within 30 days, provided direct care |
| LPN-B | Licensed Practical Nurse | Observed medication administration, assisted surveyor with inspection |
| CNS/LALD-A | Clinical Nurse Supervisor/Licensed Assisted Living Director | Interviewed regarding multiple deficiencies, acknowledged incomplete plans and policies |
| O-G | Owner/Authorized Agent | Interviewed regarding facility management and contract issues |
| C-C | Cook | Interviewed regarding facility apartments and menu |
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