Inspection Reports for Barross Cottage II LLC
806 13th Avenue, Two Harbors, MN 55616, MN, 55616
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Inspection Report
Follow-Up
Census: 9
Capacity: 10
Deficiencies: 21
Mar 13, 2025
Visit Reason
Follow-up survey to determine correction of orders found on the survey completed on December 18, 2024.
Findings
The facility had not corrected all state correction orders from the prior survey, including medication administration documentation, resident rights to come and go freely, and confidentiality of records. Additional deficiencies were noted in food service, fire safety, infection control, staff supervision, service plans, medication management, and emergency preparedness.
Severity Breakdown
Level 1: 0
Level 2: 20
Level 3: 2
Level 4: 0
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to ensure medication administration was documented correctly and medication was given per manufacturer's instructions. | Level 2 |
| Failed to ensure residents have the right to come and go freely; exit door was locked with a code not provided to all residents. | Level 2 |
| Failed to keep resident personal health and medical information private; medication administration records and communication binder were left unsecured and accessible. | Level 2 |
| Failed to maintain food service in compliance with Minnesota Food Code; refrigerator temperatures were above 41°F and thermometers were inaccurate. | Level 2 |
| Failed to ensure staff had access to a registered nurse 24/7; RN was not always reachable by phone and no backup RN contact was available. | Level 3 |
| Failed to ensure infection control standards were followed during medication administration; hand hygiene was not performed appropriately. | Level 2 |
| Failed to complete annual tuberculosis risk assessment as required. | Level 2 |
| Failed to maintain an updated emergency preparedness plan and missing resident plan. | Level 2 |
| Failed to comply with fire safety code; missing carbon monoxide detectors, magnetic locks on exit doors did not meet code requirements, and emergency generator testing was not documented. | Level 2 |
| Failed to maintain physical environment in good repair; cracked tiles, rusty vents, and taped floor transitions were noted. | Level 2 |
| Failed to develop and implement fire safety and evacuation plans with required content; fire drills and training were not conducted or documented as required. | Level 2 |
| Failed to ensure unlicensed personnel were trained and competent to perform delegated tasks including medication administration, lifting, and use of fall alarms. | Level 2 |
| Failed to complete required resident device assessments and include written instructions for use of devices such as sit-to-stand lift, fall alarms, and compression sleeves. | Level 2 |
| Failed to revise resident service plans to include all provided services and monitoring methods. | Level 2 |
| Failed to ensure unlicensed personnel demonstrated competency for medication administration and that written specific instructions were documented in resident records. | Level 3 |
| Failed to ensure unlicensed personnel were trained and competent to prepare and administer medications for residents during unplanned time away. | Level 2 |
| Failed to securely store medications during medication administration process; medication cabinet was left unlocked and unattended. | Level 2 |
| Failed to ensure medications were maintained with original prescription labels including legible expiration dates for time sensitive medications. | Level 2 |
| Failed to develop and maintain individualized treatment and therapy management plans with all required content and documentation of training and competency for delegated tasks. | Level 2 |
| Failed to ensure residents have the right to enter and leave the facility as they choose; exit door was locked with a code not provided to all residents and code was not posted. | Level 2 |
| Failed to keep resident personal health and medical information private; medication administration records and communication binder were left unsecured and accessible. | Level 2 |
Report Facts
Residents present: 9
Total licensed capacity: 10
Deficiencies cited: 22
Fines assessed: 1500
Refrigerator temperatures: 44
Refrigerator temperatures: 46
Refrigerator temperatures: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Named in follow-up letter as contact for questions |
| Cynthia Story | Certified Food Protection Manager | Named in food service inspection report |
| Sara Bents | Environmental Health Specialist | Named in food service inspection report |
| LALD/O-A | Licensed Assisted Living Director/Owner | Named in multiple findings and interviews related to training, supervision, and facility operations |
| CNS-C | Clinical Nurse Supervisor | Named in multiple findings and interviews related to training, supervision, and medication administration |
| ULP-D | Unlicensed Personnel | Named in medication administration and infection control findings |
| ULP-F | Unlicensed Personnel | Named in medication administration and resident rights findings |
| CO-E | Co-owner | Named in interview regarding door lock and staff training |
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