Colleens Caring Hands Inc.

STATE LICENSING COMPLIANCE EPOT eport #: HL306483629C Date Concluded: October 13, 2025 Name, Address, and County of Facility Investigated: Colleen’s Caring Hands Inc 2525 Bemidji Avenue North Bemidji, MN 56601 Beltrami County Facility Type: Assisted Living Facility with Evaluator’s Name: Barbara Axness, RN Dementia Care (ALFDC) Special Investigator The Minnesota Department of Health conducted a complaint investigation to determine compliance with state laws and rules governing the provision of care under Minnesota Statutes, Chapter 144G. The purpose of this complaint investigation was to review if facility policies and practices comply with applicable laws and rules. No maltreatment under Minnesota Statutes, Chapter 626 was alleged. To view a copy of the correction orders, if any, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html, or call website, please see the attached state form. PRINTED: 10/13/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30648 09/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2525 BEMIDJI AVENUE NORTH COLLEENS CARING HANDS INC BEMIDJI, MN 56601 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On September 2, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL306483629C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 IWM411 If continuation sheet 1 of 1

correction orders issued pursuant to the June 21, 2023 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey completed on June 21, 2023, found not corrected at the time of the September 12, 2023, follow-up survey and/or subject to penalty assessment are as follows: 0470-Minimum Requirements-144g.41 Subdivision 1 - $500.00 0680-Disaster Planning And Emergency Preparedness-144g.42 Subd. 10 - $500.00 0810-Fire Protection And Physical Environment-144g.45 Subd. 2 (b)-(f) 0910-Contract Information-144g.50 Subd. 2 (a-B) 0950-Designation Of Representative-144g.50 Subd. 3 1290-Background Studies Required-144g.60 Subdivision 1 - $500.00 1890-Prescription Drugs-144g.71 Subd. 20 2040-Fire Protection And Physical Environment-144g.81 Subdivision 1 The details of the violations noted at the time of this follow-up survey completed on September 12, 2023 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Also, at the time of this follow-up survey completed on September 12, 2023, we identified the following violation(s): 0110-Assisted Living Director License Required-144g.10 Subdivision 1a - $500.00 0940-Contract Information-144g.50 Subd. 2 (e; 5-7) 1620-Initial Reviews, Assessments, And Monitoring-144g.70 Subd. 2 (c-E) The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Colleens' Caring Hands Septembe r20, 2023 Page 2 these state correction orders. It is not necessary to develop a plan of correction. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $2,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in §144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in §144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in §144 G.20. CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164-0970 Colleens' Caring Hands Septembe r20, 2023 Page 3 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the MDH within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Requests for hearing may be emailed to: Health.HRD.Appeals@state.mn.us. To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. We urge you to review these orders carefully. If you have questions, please contact Jess Schoenecker at 651-201-3789. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Jess Schoenecker, Supervisor State Evaluation Team Email: jess.schoenecker@state.mn.us Telephone: 651-201-3789 Fax: 651-281-9796 HHH PRINTED: 09/20/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30648 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2525 BEMIDJI AVENUE NORTH COLLEENS CARING HANDS INC BEMIDJI, MN 56601 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 000} Initial Comments {0 000} *****ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95 this correction order(s) has appears in the far left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: Project SL30648015-1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On September 11, 2023, through September 12, STATES,"PROVIDER'S PLAN OF 2023, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a revisit at the above provider to FEDERAL DEFICIENCIES ONLY. THIS follow-up on orders issued pursuant to a survey WILL APPEAR ON EACH PAGE. completed on June 21, 2023. At the time of the survey, there were ten residents: all whom were THERE IS NO REQUIREMENT TO receiving services under the Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. As a result of the revisit, VIOLATIONS OF MINNESOTA STATE the following orders were reissued and/or issued. STATUTES. An immediate correction order was identified on The letter in the left column is used for September 11, 2023, at 2:00 p.m., issued for tracking purposes and reflects the scope SL30648015-1, tag identification 0110. and level issued pursuant to 144G.31 subd. 1, 2, and 3. As of September 12, 2023, at time of exit, the immediacy of correction order 0110 remained, and non-compliance remains at a scope and level of F. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 GF9R12 If continuation sheet 1 of 27 PRINTED: 09/20/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30648 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2525 BEMIDJI AVENUE NORTH COLLEENS CARING HANDS INC BEMIDJI, MN 56601 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 110 Continued From page 1 0 110 0 110 144G.10 Subdivision 1a Assisted living director 0 110 SS=F license required Each assisted living facility must employ an assisted living director licensed or permitted by the Board of Executives for Long Term Services and Supports.?