Cerenity Care Center on Humboldt

In the surveyor’s words

From the most serious findings on record at Cerenity Care Center on Humboldt, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 5, 2024

  Based on interview and document review, the facility failed to implement physician prescribed treatment orders for wound care, notify the physician of signs and symptoms of infection and labs results for 1 of 3 residents (R1) reviewed for wound care. This resulted in a delay of treatment for R1 when R1's right great toe trauma injury wound and left second toe trauma injury developed osteomyelitis (bone infection) and required amputation of both toes. The IJ began on 11/30/24, when R1's right great toe and left second toe were amputated. The administrator and director of nursing (DON) were informed of the IJ on 12/5/24 at 5:17 p.m. […]

• Actual harm, isolatedF689May 15, 2025

  Based on observation, interview, and document review, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents for 1 of 3 residents (R4) reviewed for falls. This resulted in actual harm when R4 fell and suffered a femur fracture. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R4's face sheet dated 5/16/25, identified diagnoses of Parkinson's disease (a disease of the central nervous system that affects movement), depression (persistent sadness), and anxiety (a common human emotion involving feelings of worry, nervousness, or unease). […]

• Actual harm, isolatedF725May 15, 2025

  Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received the care and assistance they needed in a timely manner for 4 of 5 residents (R5, R1, R3, & R6) reviewed for call lights. This caused actual harm to R5 when she waited nearly three hours for her call light to be answered causing her to experience increased anxiety, distress, fear, and feelings of worthlessness and helplessness. Findings include: R5 R5's Minimum Data Set (MDS) assessment dated [DATE], indicated she had intact cognition and no behaviors or rejections of care. R5 had diagnoses including multiple sclerosis (chronic disease affecting the central nervous system), anxiety disorder, major depressive disorder, and morbid obesity. […]

• Actual harm, isolatedF684Jul 11, 2024

  Based on interview and record review the facility failed to comprehensively assess and follow the hospital discharge orders to keep a cast completely dry for 1 of 3 residents (R1) reviewed for orders. R1 was harmed when he was admitted to the facility with a post-surgical cast covering his right leg with orders that the cast must remain dry, and the facility failed to keep the cast dry. R1 was sent to the hospital where the cast was found to be soiled with urine and feces, contributing to continuous infections. Findings include: R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. […]

• Actual harm, isolatedF686Jul 11, 2024

  Based on interview and record review the facility failed to ensure 1 of 3 residents (R1) reviewed for pressure ulcers received care consistent with professional standards of practice to prevent pressure or worsening of pre-admission pressure ulcers. R1 was harmed when the facility failed to promote healing of current pressure ulcers and prevent new ulcers from developing. R1 was admitted with two pressure ulcers, and a shearing wound on 6/26/26. R1 discharged from the facility on 7/7/14 with three pressure ulcers and the shearing wound turned into stage II pressure ulcers in multiple areas from his thigh to his mid-dorsal back. R1's hospital discharge information to the facility dated 6/25/24 indicated R1 was medically complicated. […]