Inspection Reports for Barross Cottage LLC
401 South Avenue, Two Harbors, MN 55616, MN, 55616
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Inspection Report
Routine
Census: 6
Capacity: 10
Deficiencies: 9
Aug 13, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for an assisted living facility.
Findings
The licensee was found in substantial compliance but had several deficiencies including failure to ensure food was prepared according to Minnesota Food Code, failure to maintain an effective infection control program, incomplete employee records, lack of tuberculosis screening history, failure to provide required emergency relocation notices, incomplete dementia and mental illness training for staff, expired medications in storage, failure to ensure appropriate care related to bedrail use, and failure to maintain resident privacy during medication administration.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Food was not prepared and served according to the Minnesota Food Code, resulting in a level two violation. | Level 2 |
| Failed to establish and maintain an effective infection control program; unlicensed personnel did not change gloves or perform hand hygiene between medication administrations. | Level 2 |
| Employee records lacked required annual performance reviews and job descriptions for two employees. | Level 2 |
| Failed to maintain tuberculosis prevention program including history and symptom screening for active TB for two employees. | Level 2 |
| Failed to provide written emergency relocation notice and notify Ombudsman for Long-Term Care when resident did not return within four days. | Level 2 |
| Direct care staff did not complete required initial training on mental illness and de-escalation topics. | Level 2 |
| Expired medications were found in storage including Salonpas patches, laxative powder, cough syrup, and ClearLax powder. | Level 2 |
| Failed to ensure care and services were provided according to accepted standards for a resident using a consumer bedrail; lack of recall checks on bedrail. | Level 2 |
| Failed to maintain resident privacy during medication administration in a non-private area. | Level 2 |
Report Facts
Residents present: 6
Licensed capacity: 10
Fines assessed: 500
Priority 1 Orders: 0
Priority 2 Orders: 0
Priority 3 Orders: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Named as contact for the survey and correction orders. |
| Cindy Story Fabbri | Owner | Named as licensee and responsible for employee records and facility operations. |
| Sara Bents | Public Health Sanitarian 3 | Conducted food establishment inspection. |
| ULP-E | Unlicensed Personnel | Observed failing to change gloves between medication administrations. |
| RN-G | Registered Nurse | Responsible for supervision and direct care; lacked job description and annual performance review. |
| ULP-D | Unlicensed Personnel | Employee record lacked TB screening history and symptom screening. |
| CNS-B | Clinical Nurse Supervisor | Provided interview statements regarding infection control and emergency relocation. |
| O-C | Owner | Provided multiple interview statements regarding compliance and record keeping. |
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