Cerenity Marian Of St Paul LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure the environment was free of potential hazards for 1 of 1 resident (R56) found to have a space heater operating in their room.Findings include:R56's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and no behaviors. R56 was independent with transfers and ambulation. Diagnoses included cardiopulmonary disease (heart and lung disease), diabetes and cataracts, glaucoma or macular degeneration (eye conditions that cause loss of vision).R56's Mood State care plan dated 3/12/26, identified she had a sleep pattern disturbance related to insomnia and to evaluate her room for noise, darkness, temperature and comfort.During an observation and interview on 3/16/26 at 7:42 a.m., R56 stated her room was too cool and she used a space heater provided to her from nursing. On the laminate style floor was a [NAME] brand with model number HFH610 space heater set at 84 degrees on the digital reading. The space…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation, interview, and document review the facility failed to ensure supplemental oxygen was properly maintained for 1 of 1 resident (R40) reviewed for oxygen. Findings include: R40's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia (low oxygenation) and was dependent on supplemental oxygen. R40's physician's orders indicated the following:-on 5/22/25, R40 required continuous oxygen-wean as able per nasal cannula to keep oxygen saturation greater than or equal to 90%. Oxygen at 1 LPM every shift.-on 10/1/25, order directed staff to change and date an oxygen humidifying jar monthly.R40's treatment administration record (TAR) dated 3/2026, indicated R40's humidifying jar was last changed on 3/1/26 and oxygen tubing was changed on 3/12/26.R40's Care plan dated 1/28/25, indicated R40 had ineffective breathing patterns related to chronic respiratory failure with hypoxia, dysphagia (problems swallowing) with aspiration risk.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure dishwasher temperatures were within range to ensure resident dishes were sanitized for 3 of 3 kitchenettes located on resident units. Furthermore, the facility failed to ensure expired milk was removed from 1 of 3 kitchenettes (3rd floor) and clean resident dishes were stored to prevent contamination from dust/debris for 1 of 3 kitchenettes located on resident units (4th floor). This had the potential to impact all residents who reside in the facility. Findings include: A facility document titled 3rd and 4th floor Dish Machine from Ecolab dated 2024, indicated the operating temperatures were a minimum wash temperature of 155 degrees Fahrenheit (F) and a minimum rinse temperature of 180 degrees F. A facility document titled 5th floor Dish Machine from Ecolab dated 2018, indicated the operating temperatures were a minimum wash temperature of 150 degrees F and a minimum rinse temperature of 180 degrees F. 4th floor Kitchenette A facility document titled Dish Machine Temperature Log 4th floor dated 2/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review the facility failed to report an incident involving a fall was immediately reported to the supervisor according to the facility abuse policy for 1 of 4 residents (R1) who suffered a fracture during an unsafe transfer that caused a delay in care and treatment for over 12 hours. Finding include: During interview on 8/14/24 at 1:29 p.m., R1 reported being transferred incorrectly on 7/29/24 in the shower causing her to fall; she landed on her butt with her right leg and ankle underneath herself. R1 screamed in pain and told staff she was hurt. R1 was unable to identify staff as she reported being legally blind and was not provided her hearing aids prior to the transfer. R1 reported it took a whole other day to get anyone to look at it. R1's quarterly MDS (minimum data set) dated 6/20/24, identified R1 as cognitively intact, moderate difficulty with hearing and requires the use of a hearing aids. R1 had highly impaired vision. Tub/shower transfer was not assessed (N/A). R1 required substantial/maximal assistants taking off and putting on footwear.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance they needed. This had the potential to affect all 82 residents who resided in the facility. Findings include: The 2023 Annual Facility Assessment updated October 2, 2023, indicated the facility could serve 90 residents and had an average census of 73 residents. The service and care offered based upon the needs of those served included activities of daily living (ADL) support, bowel and bladder care and toileting support, coordination of care with physician and other health care providers, end of life care, fall prevention, infection prevention, medication administration, mobility assistance, nutrition support and pain management. Additionally, had an average of 24 FTE (full time equivalent) nursing staff at full census/pay period including the director of nursing (DON), assistant DON (ADON), clinical managers, Minimum Data Set (MDS) nurse, licensed nurses,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 2 of 2 residents (R42, R1) and failed to ensure proper personal protective equipment (PPE) for 2 of 2 residents (R18, R1) observed for contact precautions and enhanced barrier precautions and failed to ensure proper cleaning of a mechanical lift following use was completed for 1 of 1 resident (R42) Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not have behaviors and did not reject care, required substantial assistance with toileting and hygiene, partial to moderate assist with bathing, dressing, substantial assist for standing and transfering, was not on a toileting program, and was frequently incontinent of bowel and bladder. R18's Face Sheet form dated 4/15/24, indicated the following diagnoses: viral intestinal infection, repeated falls, gastro esophageal reflux disease with esophagitis without bleeding. A form provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure a self administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 3 of 3 residents (R70, R11, R52). Findings include: R70's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, required set up or clean up assist for eating, oral hygiene, and required supervision for upper body dressing, partial assist for lower body dressing and supervision for personal hygiene. R70's Face Sheet form dated [DATE], indicated R70 had the following current diagnoses: metabolic encephalopathy, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, cognitive communication deficit. R70's physician orders were reviewed and lacked an order to self administer medications. An order was later added on [DATE], Ok for daily medications to be left with resident to take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide timely activity of daily living (ADL) assistance for 2 of 2 residents (R9, R38) who required staff assistance to make it out to meals. Findings include: A form, Meal Times, indicated an open breakfast from 7:30 a.m., until 9:00 a.m., and lunch was served at 11:30 a.m., on the 4th and 5th floors and at 12:00 p.m., on the 3rd floor. Dinner was served at 4:30 p.m., on the 4th and 5th floors and at 5:00 p.m., on the 3rd floor. Forms, NAR Group Sheet 1, NAR Group Sheet 2, NAR Group Sheet 3, indicated the following, mealtime reminder: must count the meal tickets to make sure that all residents have eaten, please reapproach three times and notify the nurse if a resident refuses cares. R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition, did not have physical, verbal, or other behaviors, and did not reject cares, required set up or clean up assistance with eating, substantial to maximum assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide timely referral to an outside optometry service to resolve broken eyeglasses and provide a routine follow up appointment for 1 of 1 resident (R9) reviewed whose glasses were broken. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition, had adequate vision including fine detail, including regular print in newspapers and books with glasses or other visual appliances and did not wear corrective lenses. R9's annual MDS dated [DATE], indicated R9 had adequate vision and wore corrective lenses, and it was very important to have books, newspapers, and magazines to read. R9's state optional assessment dated [DATE], indicated R9 required extensive assist for bed mobility, transfers, and toileting and was independent with eating. R9's progress notes were reviewed on 4/17/24 at 2:59 p.m., and lacked documentation of any refusals of eye exams after 8/22/22. R9's care plan dated 4/16/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure interventions were in place for 1 of 3 residents reviewed for pressure ulcers. Findings include: R183's Brief Interview & Staff Assessment for Mental Status (BIMS) dated 4/9/24, indicated R183 had moderate cognitive impairment. R183's Continuity of Care document printed 4/18/24, indicated R183's diagnoses included pressure ulcer of right heel and lymphedema. R183's Functional Abilities assessment dated [DATE], indicated R183 required substantial/maximal assistance with putting on/taking off footwear and sit to stand performance. R183's admission body audit/skin condition assessment dated [DATE], indicated R183 had a right heel wound. R183's Skin Risk Observation with Braden Scale dated 4/8/24, indicated R183 had an unhealed pressure injury on right lower heal and at risk for further skin breakdown. The assessment identified interventions which included heel protectors. R183's provider orders included the following: 4/8/24-Out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure use of a bed pan and urinal were offered and in place for 1 of 2 residents (R38) in accordance with the individualized care plan. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, did not have behaviors, did not reject cares, had upper and lower extremity impairment on one side, required supervision or touching assistance for toileting hygiene, partial to moderate assistance with upper and lower body dressing, personal hygiene, was not on a toileting program for bowels or bladder, and was frequently incontinent of bladder and bowel. R38's Face Sheet form dated 4/17/24, indicated R38 had the following diagnoses: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non dominant side, unspecified dementia, ataxia (lack of muscle coordination) following cerebral infarction, dysphagia (difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to provide a therapeutic diet as prescribed and failed to ensure adequate hydration in accordance with the individualized care plan for 1 of 2 residents (R38). Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, did not have behaviors, did not reject cares, had upper and lower extremity impairment on one side, required supervision or touching assistance for toileting hygiene, partial to moderate assistance with upper and lower body dressing, personal hygiene, and required set up or clean up assistance for eating. The MDS further indicated R38 was on a therapeutic diet. R38's Face Sheet form dated 4/17/24, indicated R38 had the following diagnoses: hemiplegia (paralysis on one side of the body) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non dominant side, unspecified dementia, ataxia (lack of muscle coordination) following cerebral infarction,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure food was served at warm, palatable temperatures for 3 of 3 residents (R9, R64, R50). Findings include: R9's quarterly Minimum Data Sets (MDS) dated [DATE], indicated R9 had intact cognition, did not have physical, verbal, or other behaviors, and did not reject cares, required set up or clean up assistance with eating, substantial to maximum assistance with showering/bathing, partial to moderate assistance with upper body dressing, personal hygiene, and was dependent on staff for lower body dressing, chair to bed and bed to chair transfers, and required substantial to maximum assistance with sitting to standing. R9's physician orders indicated the following order: • 12/18/23, RG7 (normal everyday foods of various textures that are developmentally and age appropriate. Biting and chewing ability needed.) regular texture cardiac less than 2400 milligrams (MG) of sodium diet and thin liquids. R9's Face Sheet form dated 4/17/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to label, date and store food in a sanitary manner to prevent food borne illness for food brought into the facility by a resident, family or guest. In addition, the facility failed to properly label, date and store meal trays held after meal service for 2 of 2 meal trays. This deficient practice had the potential to affect 3 of 3 residents residing on the fifth floor. Findings include: During observations on 4/15/24, at 12:40 p.m., a small glass containing orange liquid was sitting on R3's bedside table. Additionally, an open jar of salsa was observed sitting on the windowsill. At 4:43 p.m., R3 was observed in his room, and the glass that had contained the orange liquid was empty and R3 stated it was from his breakfast that morning and he drank it when he came back from an appointment at approximately 4:00 p.m. During subsequent observations between 4/15/24 at 2:03 p.m., and 4/17/24 at 07:43 a.m., the jar of open salsa remained on R3's windowsill. During tour of fifth floor kitchenette, and interview with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.