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October 14, 2025 Mohamed Jama, Authorized Agent Nicollet Senior Center LLC 3601 Nicollet Avenue Suite 100B License Number: 1117185 (Rule 223) CORRECTION ORDER Dear Mohamed Jama: On July 23, 2025, a licensing review of Nicollet Senior Center LLC located at 3601 Nicollet Avenue, Minneapolis, Minnesota, was conducted to determine compliance with Minnesota Statutes and Rules governing adult day care services under Minnesota Rules, parts 9555.9600 through 9555.9730 (Rule 223). As a result of this licensing review, a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c). Violation: For three of three participants whose records were reviewed (P1, P2, and P3), the license holder did not provide orientation to the license holder’s internal and external reporting procedures related to suspected or alleged maltreatment as required. The license holder did not provide orientation to P1, P2, and P3 on the licensor holder’s internal and external reporting procedures within 24 hours of admission. Corrective Action Required: Within 15 days of receiving this order, you must: · provide an orientation to P1, P2, and P3 on your internal and external reporting procedures; and · document that P1, P2, and P3 were provided the orientation in the participant’s records. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in these subdivisions. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one participant whose record was reviewed (P1), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP). The license holder did not develop an IAPP for P1 as part of P1’s initial individual program plan or service plan. Corrective Action Ordered: Within 15 days of receiving this order, you must develop an IAPP for P1. Within 30 days of receiving this order, you must: · review P1’s IAPP with the P1’s interdisciplinary team and document the review; · complete an audit of all participants’ IAPPs to ensure the requirements in Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b) are maintained; and · for participants whose IAPPs are not developed and reviewed as required, you must develop a plan detailing how your program will maintain IAPPs as required within 60 calendar days of receiving this order. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9555.9640. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not distribute policies and program information to participants and their caregivers upon admission as required. The license holder did not distribute the following policies and program information to P1, P2, P3 and the participants’ caregivers upon admission: · the scope of the programs, services, and care offered by the center; · a description of the population to be served by the center; · a description of individual conditions which the center is not prepared to accept, such as a communicable disease requiring isolation, a history of violence to self or others, unmanageable incontinence or uncontrollable wandering; · the center's policy on and arrangements for providing transportation; · the center's policy on providing meals and snacks; · the center's fees, billing arrangements, and plans for payment; · the center's policy governing the presence of pets in the center; · the center's policy on smoking in the center; · types of insurance coverage carried by the center; · a statement of the center's compliance with Minnesota Statutes, section 626.557, and rules adopted under that section; · a statement that center admission and employment practices and policies comply with Minnesota Statutes, chapter 363, the Minnesota Human Rights Act; · the terms and conditions of the center's licensure by the department, including a description of the population the center is licensed to serve under part 9555.9730; and · the telephone number of the department's licensing division. Corrective Action Ordered: Within 15 days of receiving this order, you must: · distribute the policies and program information listed above to P1, P2, P3, and their caregivers; and · document the distribution of the policies and program information in P1, P2, P3’s records. Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this part. 4. Citation: Minnesota Rules, part 9555.9660, subpart 1. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not include information in the participant’s written record as required. a. The license holder did not include the following information in P1’s record: · an application for that included: o P1’s source of referral; o the name and telephone number of the secondary person to call in case of an emergency involving P1; and o the name and telephone number of P1’s physician or medical provider; · a medical report dated within the three months prior or 30 days after P1’’s admission to the center. P1 was admitted to the center on January 3, 2025 and the license holder maintained a medical report for P1 on July 10, 2025; · P1’s service agreement with the center that specified the responsibilities of P1 and the center with respect to payment for and provision of services and signed by P1 or P1’s caregiver and the center director. b. The license holder did not include the following information in P2’s record: · an application for that included: o P2’s telephone number and source of referral; o the name and telephone number of the secondary person to call in case of an emergency involving P2; and o the name and telephone number of P2’s physician or medical provider; · P2’s service agreement with the center that specified the responsibilities of P2 and the center with respect to payment for and provision of services and signed by P2 or P2’s caregiver and the center director. c. The license holder did not include the following information in P3’s record: · an application for that included P3’s source of referral; · a medical report dated with within the three months prior or 30 days after P3’s admission to the center. P3 was admitted to the center on April 28, 2025 and the license holder maintained a medical report for P3 on June 25, 2025; and · P3’s service agreement with the center that specified the responsibilities of P3 and the center with respect to payment for and provision of services and signed by P3 or P3’s caregiver and the center director. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain the information detailed above in P1, P2, and P3’s records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 5. Citation: Minnesota Rules, part 9555.9700, subpart 2. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not complete initial service planning as required. a. The license holder did not conduct a needs assessment for P1 and P2 that addressed the participant’s physical status using information from the medical report received from the participant’s physician. · The license holder conducted P1’s needs assessment on January 3, 2025. The license holder did not receive the medical report from P1’s physician until July 10, 2025. · The license holder conducted P3’s needs assessment on May 15, 2025. The license holder did not receive the medical report from P3’s physician until June 25, 2025. b. The license holder did not: · conduct a needs assessment for P2 that addressed P2’s physical status using information from the medical report received from the P2’s physician. The license holder conducted P2’s needs assessment on January 5, 2025. The license holder did not receive the medical report from P2’s physician until January 24, 2025; and · develop a preliminary service plan for P2 that included the role of P2’s caregiver or caregivers in carrying out the service plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · conduct needs assessments for P1, P2, and P3 that includes the information detailed above; and · develop a preliminary service plan for P2 that includes the information and specifications detailed above. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 6. Citation: Minnesota Rules, part 9555.9700, subpart 3. Violation: For three participants whose records were reviewed (P1, P2, and P3), the license holder did not develop a written plan of care as required. The license holder did not develop written plans of care for P1, P2, and P3 that included: · an update of the preliminary service plan and additional services required by the participant; and · short and long term objectives for the participant stated in concrete, measurable and time specific outcomes; Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop written plans of care for P1, P2, and P3 that include the information detailed above; · complete an audit of all participants’ written plans of care to ensure the requirements in Minnesota Rules, part 9555.9700, subpart 3 are maintained; and · for participants who do not have a written plan of care that includes all required information, you must develop a plan detailing how your program will maintain a complete written plan of care within 60 days of receiving this order. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Rules, part 9555.9650, item A. The license holder did not maintain a copy of SP1 and SP2’s job descriptions in SP1 and SP2’s personnel records. Corrective Action Required: Within 30 days of receiving this order, you must maintain a copy of SP1 and SP2’s job descriptions in their personnel records. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this item. 8. Citation: Minnesota Rules, part 9555.9710, subpart 1. Violation: The license holder did not offer services as required. a. The license holder did not maintain a current contract with the food service provider. b. The license holder did not offer a midmorning and midafternoon snack. c. The license holder did not ensure menus for all meals and snacks were approved by a registered dietician. d. The license holder did not maintain a record indicating the menu for all meals served for at least six months.
9. Citation: Minnesota Rules, part 9555.9720, subparts 1, 5, 7 and 8. Violation: The license holder did not ensure safety as required. a. The license holder did not ensure the first aid kit contained an ice bag or cold pack. b. The license holder did not ensure equipment and furniture were in good repair, including ceiling tiles with water damage. c. The license holder did not ensure the use of potentially hazardous materials were allowed under supervision. During the licensing review that took place on July 23, 2025, DHS licensors observed a metal rod with a sharp arrow point on the end, lying on the floor of the women’s restroom. d. The license holder failed to ensure the areas used by participants were free from loose plaster and peeling paint, including peeling paint and chipped sheetrock throughout the facility.
10. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: The license holder did not establish policies and procedures related to suspected or alleged maltreatment as required. The license holder did not establish policies and procedures related to suspected or alleged maltreatment that identified the primary or secondary person or position: · to whom internal reports can be made; · responsible for forwarding internal reports to the common entry point; and · who would ensure that, when required, internal reviews were completed. The license holder’s policies and procedures identified two staff members as the primary and secondary persons, however, at the time of the licensing review, the license holder confirmed the staff members identified in the policy are no longer employed at the center. Corrective Action Ordered: Immediately, you must establish policies and procedures related to suspected or alleged maltreatment that include the information as detailed above. Additionally, you must post a copy of the internal and external reporting policies and procedures in a prominent location in the program. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Alexandra Devick, HCBS Human Services Licensor Licensing Division Office of Inspector General 651-431-4626
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