Inspection Reports for Lilly J’s Housing and Services
111 63 1/2 Way, Northeast Fridley, MN 55432, MN, 55432
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Inspection Report
Original Licensing
Census: 2
Deficiencies: 11
Apr 30, 2025
Visit Reason
The Minnesota Department of Health conducted an initial survey to assess compliance with state licensing statutes for an assisted living facility license.
Findings
The licensee was found in substantial compliance but had multiple deficiencies including incomplete employee records, lack of tuberculosis prevention program, fire safety violations, incomplete staff orientation, missing resident reassessments, medication management issues, and improper documentation of medication disposition.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Employee records lacked required content for three employees including licensure, orientation, job descriptions, health screenings, and background studies. | Level 2 |
| Failed to maintain a tuberculosis prevention and control program including TB risk assessment, baseline screenings, and training for employees. | Level 2 |
| Failed to provide interconnected smoke alarms in required locations. | Level 2 |
| Failed to maintain portable fire extinguishers with required monthly visual inspections. | Level 2 |
| Failed to maintain physical environment in good repair; egress window hardware not working in unoccupied bedroom. | Level 2 |
| Fire safety and evacuation plan lacked specific employee actions and resident fire protection procedures. | Level 2 |
| Failed to provide orientation to assisted living licensing requirements and regulations prior to providing services for one employee. | Level 2 |
| Orientation content missing required topics for one unlicensed employee. | Level 2 |
| Failed to conduct a 14-day resident reassessment for one resident. | Level 2 |
| Failed to ensure registered nurse developed training and competencies for unlicensed personnel providing medications during unplanned time away. | Level 2 |
| Failed to document disposition of medications in resident's record including medication details, quantity, date, and staff involved. | Level 2 |
Report Facts
Residents present: 2
Fine amount: 500
Days for correction: 21
Days for correction: 7
Days for correction: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Thorson | Survey Supervisor | Named as contact person and survey supervisor |
| LALD/CNS-A | Licensed Assisted Living Director/Clinical Nurse Supervisor | Named in multiple findings including employee records, tuberculosis program, fire safety, orientation, resident reassessment, medication management |
| ULP-B | Unlicensed Personnel | Named in employee records, tuberculosis program, medication management findings |
| ULP-C | Unlicensed Personnel | Named in employee records, tuberculosis program, orientation, medication management findings |
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