St Croix Health Center

In the surveyor’s words

From the most serious findings on record at St Croix Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 3, 2025

  Based 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.Findings include:Facility policy titled Dress Policy from New Horizon's Food Handbook dated December 2021, reads in part. Hair restraints while handling food including facial hair covers in accordance with state and health department regulations.On 12/01/2025 at 12:07 PM, Surveyor observed FS H temping and serving food with a hat on, beard net on, and full mustache uncovered and exposed.On 12/02/2025 at 8:15 AM, Surveyor observed FS H serving breakfast with mustache exposed and uncovered. […]

• No harm, potential for more than minimal, widespreadF868Dec 3, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Sep 18, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF812Aug 30, 2023

  Based 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) Findings include: On 08/28/23 at 12:20 PM, Surveyor observed Certified Nursing Assistant (CNA) H pick up the top bun from R79's plate with bare hands to place it on the burger. CNA H then held the bun with bare hands when cutting it in quarters for R79 to eat. On 08/28/23 at 12:28 PM, Surveyor observed CNA D remove the top bun from R14's burger with bare hands to put ketchup on the burger. CNA D then placed the bun back on the burger with bare hands. […]

• No harm, potential for more than minimal, patternF700Jul 28, 2022

  Based on observation, interview, and record review, the facility did not assess resident risk for entrapment or attempt alternative methods prior to installing bedrails for 6 of 6 Residents (R) reviewed (R87, R3, R23, R185, R10, R85.) R87, R3, R23, R185, R10, and R85 had grab bars on their beds without an assessment completed to determine their risk for entrapment and without first attempting alternate methods prior to installing the rails on their beds. This is evidenced by: Example 1: On 07/25/22 at 11:45 a.m., Surveyor observed R87's bed having bilateral grab bars. Review of R87's medical record documented current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was a recent admission to the facility and the Minimum Data Set (MDS) was not completed. […]