Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Croix Health Center during CMS and state inspections, most recent first.
Food service safety standards were not followed when a Food Server temped and served food with a beard net and hat on but with the mustache left uncovered. Surveyors observed the issue during food service, and kitchen leadership confirmed that facial hair, including the mustache, must be covered by the restraint.
The facility did not ensure the QAA/QAPI committee included the required MD at quarterly meetings. The DON stated the MD missed the last two meetings and only received the meeting information for review, while the NHA confirmed the MD did not attend and that the clinic was reorganizing with the current physician leaving and the MD retiring. Surveyors found no evidence that the MD was involved in the meetings or that an acceptable alternative attended in the MD's place.
PRN psychotropic orders lacked required end dates for two residents. One resident on hospice with bipolar disorder and dementia had a PRN Lorazepam order listed as indefinite, and another resident with Alzheimer’s disease and anxiety had a PRN Lorazepam order without an end date while receiving the medication repeatedly over several months. Staff interviews showed awareness that PRN psychotropics are generally limited to 14 days unless renewed, but the facility did not have a policy or procedure for PRN psychotropics.
Staff failed to maintain proper infection control during incontinence care for two residents. CNAs did not change gloves or perform hand hygiene when moving between dirty and clean tasks, used contaminated washcloths and sink surfaces during peri care, and handled clean clothing and transfers without appropriate hand hygiene. One resident had Parkinson's disease and dementia, and the other resident's care included repeated glove changes without hand hygiene and use of a washcloth taken from the bathroom sink.
The facility was found to have deficiencies in food service sanitation practices, affecting all residents. Nutritional Aide F did not follow proper hand hygiene, touching her glasses while preparing food, and failed to allow the thermometer probe to air dry after sanitizing. Additionally, staff did not wear hair restraints as required. These lapses were observed and documented by the surveyor.
A facility failed to conduct a required Minnesota background check for a CNA who had resided in Minnesota, despite having a policy to screen for abuse, neglect, or mistreatment. The oversight was discovered during a surveyor's review, revealing that only a Wisconsin background check was on file, potentially compromising resident safety.
A resident with severely impaired cognition and incontinence did not receive necessary incontinence care for four hours, contrary to their care plan. The resident's care plan required regular checks and changes to prevent skin injury, but staff failed to follow this plan. A CNA unfamiliar with the resident's routine did not perform peri care, and the Nursing Supervisor acknowledged the lapse in care. The facility lacked a specific ADL policy for dependent residents.
A resident with severely impaired cognition and immobility was not repositioned for four hours, contrary to their care plan, increasing the risk of pressure injuries. The facility's policy on skin breakdown prevention was not followed, as staff failed to adhere to the required repositioning schedule. The Nurse Supervisor confirmed the deficiency, acknowledging the resident's risk for pressure injuries due to immobility and incontinence.
A resident with impaired mobility and cognition did not receive prescribed passive range of motion (ROM) exercises during morning care, as observed by a surveyor. The care plan required daily ROM exercises, but the CNA was unaware of this requirement, leading to only seven documented instances of ROM over three months. The Nurse Supervisor confirmed the expectation for daily ROM to prevent further contractures.
The facility failed to ensure resident safety by not conducting a smoking risk assessment for a resident who smoked despite the non-smoking policy and by not implementing care plan interventions for a fall-risk resident. The smoking resident was observed unsupervised outside, and the fall-risk resident was left on a high bed without a fall mat. Staff were aware of these issues but did not follow care plan directives or complete necessary assessments.
Improper Facial Hair Restraint During Food Service
Penalty
Summary
Food was not distributed and served in accordance with professional standards for food service safety because Food Server H did not fully cover facial hair while temping and serving food. Facility policy in the Food Handbook required hair restraints, including facial hair covers, in accordance with state and health department regulations. Surveyors observed Food Server H on multiple occasions with a hat and beard net on while the full mustache remained uncovered and exposed, including during food temping and breakfast service. Interviews with kitchen staff and the Dietary Manager confirmed that facial hair must be covered and that the beard restraint should also cover a mustache, and the Dietary Manager acknowledged the improper use of hair restraints.
QAA Committee Lacked Required MD Participation
Penalty
Summary
The facility did not ensure the Quality Assessment and Assurance (QAA) committee included the required Medical Director (MD) at the Quality Assurance Process Improvement meetings each quarter. During interview, the DON stated the MD had not attended the last two meetings on 11/20/25 and 08/21/25, and that meeting information was only sent to the MD for review and possible additions. The NHA stated the MD did not attend the meetings and that the clinic was reorganizing, the current physician was leaving, and the MD was retiring, with the facility hoping the new physician would also serve as MD. The surveyor found no evidence that the MD was simultaneously involved in the QAPI meetings or that an acceptable alternative attended in the MD's place.
PRN Psychotropic Orders Lacked Required End Dates
Penalty
Summary
The facility did not ensure that 2 of 6 residents reviewed were free from unnecessary psychotropic medications related to excessive duration. One resident, who had diagnoses including bipolar disorder and unspecified dementia with behavioral disturbance and was on hospice, had a Lorazepam 2 mg/mL concentrate order for 0.5 mg by mouth every 2 hours as needed for anxiety, restlessness, and insomnia with no stop date and listed as indefinite. Surveyor interviews with an LPN, a charge nurse, and the NHA and DON showed staff understood PRN psychotropics were generally good for 14 days unless renewed, but also stated providers sometimes ordered them indefinitely and that this resident’s order did not have an actual end date. A second resident with Alzheimer’s disease and other specified anxiety disorders was prescribed Lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety without a required end date. Record review showed the resident received PRN Lorazepam multiple times over several months, including 6 doses in May, 7 in June, 10 in July, 8 in August, 4 in September, 1 in October, none in November, and 2 doses on 12/02/25. The surveyor identified that the facility did not have a policy or procedure for as-needed psychotropic medications, and both residents’ orders were maintained without the required end date.
Infection Control Lapses During Incontinence Care
Penalty
Summary
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, R7 and R24. During observed incontinence care, staff did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and staff used contaminated high-touch environmental surfaces during resident care. R24 was admitted with diagnoses including Parkinson's disease and dementia. On observation, a CNA provided morning care while R24 was on the toilet after being incontinent of urine and having a small bowel movement. With gloved hands, the CNA cleansed the rectal area, used wet washcloths placed in and taken from the bottom of the bathroom sink, and used body soap to cleanse the front and back peri areas. The CNA then pulled up clean pants, hooked R24 into a mechanical lift, and operated the lift to position the resident into a wheelchair without removing the contaminated gloves or performing hand hygiene. For R7, two CNAs assisted with personal care and transfers while repeatedly failing to perform hand hygiene between glove changes and after contaminated tasks. One CNA placed a clean washcloth in the bottom of the sink, removed gloves, washed hands for less than 20 seconds, and later used a washcloth that had been set aside in the bathroom sink and was described as contaminated to wash the resident's groin and penis. Staff also removed and reapplied gloves without hand hygiene while dressing the resident, transferring the resident to and from the toilet, and handling clean clothing after peri care. The DON stated hand soap should not be used for cares, the washcloth should not be placed in the sink, and hand hygiene should be completed with every glove change, while a CNA stated the expectation would be to change gloves and perform hand hygiene when going from dirty to clean areas.
Deficiencies in Food Service Sanitation Practices
Penalty
Summary
The facility was found to have deficiencies in food service sanitation practices, potentially affecting all 42 residents. Nutritional Aide (NA) F was observed preparing and serving lunch without adhering to proper hand hygiene protocols. NA F repeatedly touched her reading glasses while preparing food and did not wash her hands afterward, leading to potential cross-contamination. Additionally, NA F did not allow the thermometer probe to air dry after sanitizing it with alcohol before inserting it into various food items, contrary to the facility's policy. NA F admitted to not being instructed on the proper procedure for using the thermometer and acknowledged the need for hand hygiene after touching her glasses. Further observations revealed that staff did not wear hair restraints while preparing food or being present in the kitchenette, as required by the facility's policy. Certified Nursing Assistant (CNA) H was seen preparing food without a hair restraint and was unaware of the requirement. The Dietary Manager (DM) G confirmed the expectation for staff to wear hair restraints and acknowledged the need for collaboration with the Director of Nursing to address this issue with the CNAs. These lapses in sanitary practices were documented by the surveyor, highlighting a lack of adherence to established food safety protocols.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to adhere to its own procedures designed to prevent abuse, neglect, and exploitation of residents by not conducting a required Minnesota background check for a staff member who has direct contact with residents. This deficiency was identified during a surveyor's review of eight employees' background checks, where it was found that one Certified Nursing Assistant (CNA) had only a Wisconsin background check on file, despite having resided in Minnesota within the last three years. The facility's policy mandates that potential employees be screened for any history of abuse, neglect, or mistreatment, which includes conducting a criminal background check and consulting the Caregiver Background Registry upon hire. During an interview, the Nursing Home Administrator (NHA) stated that criminal background checks are completed every four years and should include checks for states where staff have resided in the last three years. However, the NHA was unable to provide a Minnesota background check for the CNA in question, only producing a Wisconsin check dated from 2017. The NHA acknowledged the oversight and indicated that a Minnesota background check was being conducted at the time of the survey. This lapse in following the facility's abuse prevention policy potentially compromised resident safety.
Failure to Provide Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident with severely impaired cognition and dependency on staff for bed mobility, transfer, and hygiene. The resident, who is always incontinent of bowel and bladder, was observed by the surveyor to have not received incontinence care for four hours while being up in a wheelchair. The care plan for the resident indicated a need for regular checks and changes upon arising, before/after meals, at bedtime, and during night rounds to prevent skin injury. During the survey, a Certified Nursing Assistant (CNA) who was unfamiliar with the resident's routine did not perform peri care, as the resident was not incontinent at the time of the check. The Nursing Supervisor confirmed that the resident is at risk for pressure injuries due to immobility and incontinence and expressed that staff did not follow the care plan as expected. The facility lacked a specific policy for Activities of Daily Living (ADL) for dependent residents, relying instead on staff expectations to provide needed care.
Failure to Prevent Pressure Injuries Due to Inadequate Repositioning
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent the development of pressure injuries for a resident identified as R2. R2, who has severely impaired cognition and is dependent on staff for bed mobility, transfer, and hygiene, was observed to be at risk for pressure injuries. The resident's care plan included specific instructions for repositioning and changing, which were not followed by the staff. During the observation, R2 was left in a wheelchair for four hours without repositioning, contrary to the care plan's requirements. The surveyor noted that the facility's policy on the prevention and treatment of skin breakdown was not adhered to, as evidenced by the lack of repositioning for R2. Interviews with the CNAs and the Nurse Supervisor revealed that the staff did not follow the care plan, which required regular repositioning to prevent pressure injuries. The Nurse Supervisor acknowledged that R2 was at risk for pressure injuries due to immobility and incontinence and confirmed that the staff's failure to reposition R2 as per the care plan was unacceptable.
Failure to Provide Prescribed ROM Exercises
Penalty
Summary
The facility failed to provide necessary services to prevent further decrease in range of motion (ROM) for a resident with impaired mobility. The resident, who has severely impaired cognition and is dependent on staff for mobility, was observed not receiving the prescribed passive ROM exercises for her legs during morning care. The care plan and kardex guidelines specified that passive ROM should be performed every morning, but the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of this requirement and did not perform the exercises. The resident's documentation over the past three months showed that ROM exercises were only completed on seven occasions, indicating a significant lapse in care. The Nurse Supervisor confirmed that the expectation was for CNAs to perform ROM exercises for each joint of the resident's legs every morning to prevent further contractures. However, the lack of awareness and execution of the ROM program by the CNA staff contributed to the deficiency in care provided to the resident.
Deficiencies in Resident Safety and Care Plan Implementation
Penalty
Summary
The facility failed to ensure resident safety by not conducting a smoking risk assessment or implementing care plan interventions for a resident who smoked despite the facility's non-smoking policy. The resident, who had intact cognition and used a motorized wheelchair, was observed smoking outside the facility without supervision. The facility's staff were aware of the resident's smoking habits but did not have a policy for assessing smoking risks or interventions to ensure the resident's safety. Another deficiency involved a resident identified as a fall risk, who was observed sitting unsupervised on the edge of a high-positioned bed without a fall mat in place. The resident's care plan required the bed to be in a low position with a mat on the floor to prevent falls. However, a CNA failed to follow these care plan directives, leaving the resident at risk of falling. The CNA was not fully familiar with the resident's care needs and did not adhere to the care plan instructions. The facility's failure to complete a fall risk assessment for the resident after a previous fall further contributed to the deficiency. The resident had a history of attempting to get out of bed, and the lack of adherence to the care plan increased the risk of injury. The facility's policies on accident/incident reporting and care plan updates were not effectively implemented, leading to these safety oversights.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deerfield Care Center, Llc | 1.1 mi | ★★★★★ | 4 | 0 |
| Hammond Health Services | 12 mi | ★★★★★ | 3 | 0 |
| The Estates At Linden Llc | 13.1 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Stillwater | 13.4 mi | ★★★★★ | 9 | 0 |
| The Estates At Greeley Llc | 13.6 mi | ★★★★★ | 0 | 0 |
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