Inspection Reports for
Lilydale Senior Living

0480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services: The evaluator found food was not prepared and served according to the Minnesota Food Code as evidenced by identified food code violations documented in the facility's Food and Beverage Establishment Inspection Report, including an encrusted convection oven interior.

01290 144G.60 Subdivision 1 Background studies required: The licensee failed to ensure a staff member's DHS background study was current and completed before providing unsupervised direct care; one unlicensed employee (ULP-F) had an incomplete/closed background study and was removed from the schedule pending fingerprinting and clearance.

01620 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring: The licensee failed to complete a comprehensive reassessment with a change of condition when a resident (R6) started hospice and required increased assistance, i.e., no change-of-condition assessment was documented.

02320 144G.91 Subd. 4 (b) Appropriate care and services: Nurse-delegated medication administration procedures were not followed by an unlicensed staff (ULP-F) who administered medications without properly checking the bubble pack label against the MAR for residents (R1 and R2).

0620 144G.42 Subd. 6 (a) Compliance with requirements for reporting maltreatment: The facility failed to report sufficient details to the common entry point about an incident in which a resident was found deceased and entrapped in a siderail, reporting the incident as "self-neglect" and omitting the extent of entanglement.

02310 144G.91 Subd. 4 (a) Appropriate care and services: The facility failed to provide care and services according to accepted standards for fifteen residents using bed rails, lacking individualized risk/benefit assessments, manufacturer guidance, installation and maintenance documentation, and regular physical inspections, creating an imminent entrapment risk.

02360 144G.91 Subd. 8 Freedom from maltreatment: The facility failed to ensure one resident was free from maltreatment; MDH determined maltreatment occurred and the facility was responsible.

03020 626.557 Subd. 4 Reporting: The facility failed to immediately provide sufficient information to the common entry point about the resident's death and entrapment, reporting the event as self-neglect and not accounting for the possibility of facility neglect.

0480 144G.41 Subd 1 (13) (i) (B) Minimum requirements: This Minnesota requirement is not met as evidenced by the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

0510 144G.41 Subd. 3 Infection control program: This Minnesota requirement is not met as evidenced by staff were observed wearing soiled gloves and failing to perform hand hygiene after providing personal cares and medication tasks.

0780 144G.45 Subd. 2 (a) (1) Fire protection and physical environment: This Minnesota requirement is not met as evidenced by the licensee failed to provide a required smoke alarm outside a bedroom and failed to interconnect smoke alarms in several apartment units.

0810 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment: This Minnesota requirement is not met as evidenced by the fire safety and evacuation plan lacked required content, training records were incomplete, and the facility did not meet the minimum frequency of employee evacuation drills.

0970 144.50 Subd. 5 Waivers of liability prohibited: This Minnesota requirement is not met as evidenced by the assisted living contract included language that waived or limited the facility's liability for residents' health, safety, or personal property.

01370 144G.61 Subd. 2 (a) Training and evaluation of unlicensed personn: This Minnesota requirement is not met as evidenced by an unlicensed staff member lacked required training/competency documentation (including wheelchair use with footrests) per training requirements.

01880 144G.71 Subd. 19 Storage of medications: This Minnesota requirement is not met as evidenced by medications (including insulin pens) were stored in a resident refrigerator that was not secured so only authorized personnel had access.

01890 144G.71 Subd. 20 Prescription drugs: This Minnesota requirement is not met as evidenced by the licensee maintained expired house-stock medications that were not properly disposed of.

02040 144G.81 Subdivision 1 Fire protection and physical environment: This Minnesota requirement is not met as evidenced by the licensee did not provide a site-specific hazard vulnerability or safety risk assessment with mitigations for the memory care property.