St Crispin Living Community
ST CRISPIN LIVING COMMUNITY in RED WING, MN — inspection on March 19, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 3/18/26 at 12:33 p.m., licensed practical nurse (LPN)-A stated not many residents have orders for orthostatic blood pressure monitoring. LPN-A stated orthostatic blood pressure monitoring would be a provider order or a task populated from the care plan. LPN-A stated R49 did not have a provider order or care planned task for orthostatic blood pressure monitoring. LPN-A was unsure why someone on antipsychotic medication would need orthostatic blood pressure monitoring.
During an interview on 3/19/26 at 9:32 a.m., Regional Director of Clinical Services (RCS) and Registered Nurse (RN)-A stated when a resident is started on an antipsychotic, such as Risperdal, the facility has a protocol they implement to ensure side effect and symptom monitoring is completed. RCS stated side effect monitoring included orthostatic blood pressure monitoring. RCS and RN-A confirmed orthostatic blood pressure monitoring orders and care planned tasks were not completed for R49. RCS stated orthostatic blood pressure monitoring is important for residents taking antipsychotic medications because low blood pressure can be a side effect of the medications. A facility policy for psychotropic medication monitoring was asked for and was not received.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245449 03/19/2026
St Crispin Living Community 213 Pioneer Road Red Wing, MN 55066
During an observation on 3/17/26 at 5:44 p.m., R3 had multiple long hairs on her upper lip and multiple long hairs on her chin.
During an observation and interview on 3/18/26 at 10:06 a.m., R3 stated she does not like the hairs on her face (upper lip and chin), stated she had told staff that she wanted them removed but no one has helped her. R3 stated she wonders why they don't do it on bath days, that would be the easiest.
During an interview on 3/18/26 at 12:29 p.m., nursing assistant (NA)-C confirmed R3 had several long hairs on both her upper lip and chin. NA-C stated facial hair removal or shaving occurred on bath days.
NA-C stated R3 is very particular about who provides her care; R3 will complete tasks without issue if she trusts you. NA-C confirmed R3 had not refused bathing/grooming assistance in the last month.
During an interview on 3/18/26 at 12:33 p.m., licensed practical nurse (LPN)-A stated R3 will refuse cares if she doesn't know or trust you. LPN-A stated when a nursing assistant tells her the resident is refusing something, LPN-A will make sure to ask a trusted nursing assistant to complete the task.
LPN-A confirms hair removal and grooming typically occurs on bath days. LPN-A stated she did see the long hairs on R3's upper lip and chin while administering medications this morning. LPN-A stated she was aware the facial hair bothered R3; she would go back and assist R3 with hair removal in a little bit.
During an interview on 3/18/26 at 12:41 p.m., regional director of services (RDS) stated facial hair removing and grooming typically occurs on bath days. RDS stated the expectation is facial hair on women is removed as it grows, as it is care planned, and generally on bath days. RDS confirmed R3 has an order to shave on bath days and there were no documented refusals of grooming/hygiene care.
RDS stated it is important the resident's grooming needs are met, especially if the lack of grooming was upsetting to the resident.
245449 03/19/2026
St Crispin Living Community 213 Pioneer Road Red Wing, MN 55066
During an interview on 3/18/26 at 12:11 p.m., housekeeper (H)-A stated they are responsible for cleaning the dining rooms and common areas.
They do not clean resident use refrigerators.
During an observation on 3/18/26 at 3:25 p.m., the 1st floor refrigerator located near the dining room contained a clear plastic container of fresh pineapple.
The container had a room number however was not dated.
During an interview on 3/18/26 at 3:37 p.m., the dietary manager (DM) stated dietary staff are responsible for checking the temperature of the refrigerators however housekeeping cleans and checks dates of the food twice a week.
The DM also stated staff have a habit of putting their personal food items in the refrigerator.
During an interview on 3/18/26 at 3:55 p.m., the environmental services director stated dietary staff are responsible for checking the temperature of the refrigerators.
One housekeeper is responsible for cleaning resident rooms on each floor. A float housekeeper is responsible for cleaning and checking the dates and labels of food items in the resident refrigerators weekly.
The environmental services director stated staff should not be putting personal foods in the resident refrigerator and confirmed the items in question were not dated or labelled appropriately.
During an interview on 3/19/26 at 7:20 a.m., H-B stated the resident refrigerator is checked weekly by the common area housekeeper.
During an interview on 3/19/26 at 10:37 a.m., the Regional Director of Clinical Services (RCS) stated housekeeping staff are responsible for cleaning the resident refrigerators and ensuring all food items are dated and labeled appropriately twice a week.A policy titled Safe Food Storage and Handling for Food Brought in by Residents, Families, and visitors dated 2019 indicated All food stored in the refrigerator/freezer units should be in covered, seamless containers or otherwise suitably protected with date the product was given to the community for storage, use by date (max of 3 days) name and room number of resident.
Storage of large quantities of food in oversized containers should be avoided.
The policy also indicated All residents should be verbally informed that a product has been placed for them in storage and that all products not used within 3 days will be discarded.
Single-use containers such as cottage cheese and salad dressing containers cannot be re-used for direct food storage.
245449 03/19/2026
St Crispin Living Community 213 Pioneer Road Red Wing, MN 55066
During record review, R49's daily weights fluctuated with inconsistent readings noted at several intervals.
Weight measurements included:-3/16/25: 132-4/9/25: 128-4/22/25: 129-4/23/25: 128-8/4/25: 123-8/13/25: 134-8/18/25: 118-8/19/25: 130-11/19/25: 142-12/14/25: 100-12/19/25: 213-12/24/25: 141-3/12/26: 145 R49's dietary supplements were adjusted on the following dates:-3/21/25: start Glucerna (nutritional supplement drink) 8 oz in the morning w/breakfast-3/27/25: increase Glucerna 8 oz twice per day-4/15/25: change to Ensure (nutritional supplement drink) 8 oz twice per day-12/15/25: change to Ensure 8 oz daily-1/26/26: discontinue supplement
During an interview on 3/19/26 at 12:33 p.m., Regional Director of Services (RDS) reviewed R49's weight documentation; confirmed weight documentation is inconsistent and likely incorrect. RDS stated inaccurate weight documentation should have been deleted.
During an interview on 3/19/26 at 2:23 p.m., registered dietician (RD) stated R49's weight has fluctuated for some time. RD stated she had previously asked facility staff to assist her with getting and documenting accurate weights. RD stated she asked for a weight verification order on 3/11/26; obtain resident weight two times x 1 week on 3/12/26 and on 3/15/26.
A weight was documented on 3/12/26, but there was no documentation of weight in the treatment administration record (TAR) nor a progress note indicating why the order was not completed on 3/15/26. RD stated it has been difficult to make dietary supplement recommendations due to the inaccuracy of R49's documented weights.
During interview on 3/19/26 at 3:36 p.m., RDS confirmed again the inaccurate weights for R49 should have been deleted. RDS confirmed how difficult it could have been to manage R49's dietary supplements when the documented weights were inaccurate. RDS stated it is important to get accurate weights and document appropriately to ensure residents get the correct treatment based on accurate information. A facility policy for accurate charting was requested and not received.
245449 03/19/2026
St Crispin Living Community 213 Pioneer Road Red Wing, MN 55066
resistance for 1 of 1 resident (R55) reviewed for multiple urinary tract infections.Findings
cognition impairment, and substantial assistance with activities of daily living. R55 had diagnoses including hypertensive heart failure, diabetes mellitus with diabetic chronic kidney disease, and benign prostatic hyperplasia (prostate enlargement) with lower urinary tract symptoms.R55's January 2026 medication administration record (MAR) identified R55 was administered Macrobid (nitrofurantoin) 100 mg capsule, by mouth 2 times a day from 1/13/26 to 1/18/206 for urinary tract infection.Review of R55's medical record identified a urine analysis was completed on 01/10/26, result received on 1/11/26 indicated positive urine analysis.
Urine culture results received on 1/15/26 indicated organisms identified as Proteus mirabilis with sensitivity to the following antibiotics: Ampicillin, Piperacillin /tazobactam, Cefazolin, Ceftazidime, Ceftriaxone, Cefepime, Aztreonam, Ertapenem, Meropenem, Gentamicin, Tobramycin, Levofloxacin, Trimethoprim/Sulfamethoxazole.R55 was treated with an antibiotic not sensitive to the organism identified based on the urine culture result.R55's 72-Hours Antibiotic time out (a formal structured reassessment of a patient antimicrobial therapy conducted 48-72 hours after initial administration of antibiotic) review completed on 1/16/26 indicated McGeer ?s Criteria (standardized surveillance definition used to identify and track infections such as urinary tract infection) to treat indicated, met.R55's record review indicated McGeer ?s Criteria and culture was not met.R55 's March 2026 MAR identified R55 was administered ciprofloxacin 250 mg by mouth 2 times a day from 03/6/26 to 03/13/26 for urinary tract infection.Review of R55's medical record identified no urine analysis was ordered or completed before or after the start of the antibiotic.R55's 72 -Hours Antibiotic time out review completed on 3/10/26 indicated, McGeer ?s Criteria to treat was not met, and culture or imaging test did not confirm infection.During an Interview on 3/19/2026 11:19 a.m., the infection preventionist (IP) acknowledged 72 -Hours Antibiotic time out reviews completed on 1/16/26 and 3/10/26 lacked accuracy and follow up on issues identified.Facility policy titled: Antibiotic Stewardship Program and Community Protocols reviewed on 3/2025 indicated, based on review of the clinical situation, pertinent lab and diagnostic tests, the provider and nursing associate will identify whether antibiotics are warranted or whether those that have already been started should continue or change.