St. Croix Health Center

Inspectors wroteBased on observation, interview and record review, the facility did not distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all 38 residents. Food Server (FS) H did not cover facial hair while temping and serving food.

Inspectors wroteBased on interview and record review the facility did not ensure the Quality Assessment and Assurance (QAA) committee required the Medical Director (MD) to attend the Quality Assurance Process Improvement meetings each quarter. This has the potential to affect all 38 residents. This is evidenced by:On 12/03/25 at 2:36 PM, Surveyor interviewed Director of Nursing (DON) B about Quality Assurance Process Improvement (QAPI) meetings and who should be in attendance at these meetings. DON B stated the Medical Director (MD) has not attended the last two meetings on 11/20/25 and 08/21/25. The meeting information is sent to MD to review and if additional information is to be added. Nursing Home Administrator A (NHA) is in contact with the clinic for a new MD and physician. The current physician is leaving, and MD is retiring and NHA A is hoping the new physician will also be the MD. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 6 residents reviewed were free from unnecessary medications in relation to excessive duration. R2 was prescribed Lorazepam 2MG/ML Concentrate (0.25 ml / 0.5mg) by mouth every 2 hours as needed without a required end date. R27 was prescribed Lorazepam 0.5mg by mouth every 6 hours as needed for anxiety without a required end date.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for 2 of 13 residents (R) (R7, R24)Staff did not change gloves or perform hand hygiene during observation of incontinence cares for R7 and R24. Staff utilized contaminated high touch environmental surfaces to conduct resident cares for R7 and R24.

Inspectors wroteBased on observation, record review and interview, the facility did not serve foods in a sanitary manner which has the potential to affect all 42 residents. Nutritional Aide (NA) F touched her reading glasses several times when preparing and serving lunch without performing hand hygiene and continuing to serve foods. While checking the lunch foods temperatures NA F did not allow the thermometer probe to air dry after sanitizing with alcohol and before inserting into foods. Staff did not wear hair restraint when preparing food and when in the kitchenette where food was being served. This is evidenced by: Surveyor requested and received facility policies as follows: ~Handwashing dated 2010 notes: Policy: Staff will wash hands frequently as needed throughout the day following proper hand washing procedure. Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow procedures that prohibit and prevent abuse, neglect, and exploitation of residents. The facility did not perform a Minnesota background check in the last 4 years for a staff member that has direct contact with residents. This was found for 1 of 8 staff members investigated for background check compliance.

Inspectors wroteBased on observation, record review and interview, the facility did not provide necessary services to maintain good personal hygiene for 1 of 3 residents (R) observed for care (R2). This is evidenced by: Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS), completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility, transfer and hygiene. R2 is always incontinent of bowel and bladder. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. Surveyor reviewed R2's care plan and noted: Need: I have the potential to have skin injury Goal: keep my skin healthy and intact Date: 08/09/24 three months Approach: Check and change me upon arising, before/after meals at bedtime and on night rounds. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not provide the necessary care and treatment to prevent the development of pressure injuries for 1 of 3 residents (R) reviewed for pressure injuries (R2). This is evidenced by: Surveyor requested and reviewed the facility policy titled Prevention and Treatment of Skin Breakdown dated as most recently updated on 5/2024. The policy in part read: Purpose: To properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures . Procedure: ~Prevention of Pressure Ulcers: Braden Scale will be done: Upon admission Review quarterly Annually. Surveyor reviewed R2's most recent Minimum Data Set (MDS) which was a quarterly assessment completed on 8/06/24. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not provide the necessary services in attempt to prevent any further decrease in range of motion for 1 of 3 residents (R) reviewed (R2). This is evidenced by: Surveyor requested the facility policy regarding Restorative/Range of Motion (ROM) programs. Nursing Home Administrator (NHA) informed Surveyor the facility does not have a policy regarding ROM programs; it is an expectation Certified Nursing Assistants perform ROM. Surveyor reviewed R2's most recent quarterly Minimum Data Set (MDS), completed on 8/06/24. The MDS notes R2 is understood, usually understands and has severely impaired cognition. R2 is dependent on staff for bed mobility and transfer. R2 has range of motion impairment on one upper extremity. R2 uses a wheelchair. R2's diagnoses include heart failure, renal insufficiency and non-Alzheimer's dementia. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident safety through assessment and that the environment remains free of accident hazards as is possible for 2 of 4 residents (R) R31 and R2 reviewed. Facility did not complete a smoking risk assessment or implement care plan interventions for smoking safety for R31. R2 was evaluated by the facility to be a fall risk. R2 was observed sitting unsupervised on edge of bed in high position and fall mat not in place.

Inspectors wroteBased on observation and interview, the facility did not ensure food was distributed, and served in accordance with professional standards for food service. This affected 4 of 33 residents (R). Surveyors observed staff touching ready to eat foods with bare hands during food service and set up for 4 residents. (R79, R14, R18, and R3)

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 12 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. (R280) R280 was not offered and did not receive toileting every hour as care plan stated.

Inspectors wroteBased on observation, interview and record review, the facility did not provide the services necessary to maintain Range of Motion (ROM) for 1 of 1 resident reviewed. (R3) R3's care plan indicated R3 should wear a palm protector on left hand due to contractures. Throughout the survey on 08/28/23 and 08/29/23, Surveyor observed R3 wearing a palm protector on her right hand, providing no measures for R3's left hand contracture. This is evidenced by: R3 was admitted to the facility in 2018 with diagnoses including contracture of left hand, dementia, depression, and anxiety. The Minimum Data Set (MDS) dated [DATE] indicated R3 has limited ROM to upper extremity on one side, requires one person assistance with eating, dressing, toileting and completing personal hygiene. R3's most recent occupational therapy (OT) services were in December 2022. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less. During medication administration task, Surveyor observed 5 errors out of 30 medication opportunities, resulting in an error rate of 16.67%. This affected residents (R79, R83, and R21) 3 of 6 residents in the medication administration sample. R79 and R83 were administered insulin inappropriately based on technique errors while using insulin pens. The pen was not primed before administration, and the pen was not held to ensure the full dose was administered, resulting in two errors. R21 was administered 3 crushed oral medications that were extended release (ER)/enteric coated (EC). Doing so can result in too much of the medication given at once and not spread out over time as intended, resulting in three errors. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 6 residents reviewed during medication administration task (R21) was free of significant medication errors. The facility did not ensure R21 was administered crushed oral medication inappropriately based on the observation of Licensed Practical Nurse (LPN) I crushing Metoprolol Succinate Extended Release (ER). ER tablets are not to be crushed or chewed. Doing so can result in too much of the medication given at once and not spread out over time as intended, along with increasing the risk of lowering the blood pressure or heart rate to critical low levels. This is evidenced by: The facility policy, entitled Oral Medication Administration, dated 05/18, states: .Refer to crushing guidelines (See Appendix 6: [...]