Cerenity Marian of St Paul LLC

In the surveyor’s words

From the most serious findings on record at Cerenity Marian of St Paul LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 16, 2024

  Based on observation, interview, and document review the facility failed to provide safe transfers according to the care plan, to prevent or mitigate risk of falls and/or falls with major injury, for 4 of 4 residents (R1, R2, R3, R4) who required staff assistance to transfer. This resulted in an immediate jeopardy (IJ) for R1 when she suffered an ankle fracture during a transfer. The IJ began on 7/29/24 when NA-A did not follow R1's care plan to use a standing lift (EZ-Stand) for transfers, R1 became weak and was assisted to the floor resulting in R1's ankle fracture and probable posterior malleolar fracture. The Administrator and director of nursing (DON) were notified of the immediate jeopardy on 8/15/24 at 3:19 p.m. […]

• Actual harm, isolatedF760Feb 6, 2025

  Based on interview and document review the facility failed to ensure medications were administered per physicians' orders for 2 of 2 (R6, R150) residents reviewed for medication errors. This resulted in significant medication errors and actual harm when R6 received the wrong medications resulting emergent care and hospitalization for hypotension (low blood pressure), lethargy, and possible aspiration. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicate R6 had severe cognitive impairment and diagnoses of dementia, depression and high blood pressure. Furthermore, R6's MDS indicated R6 did not take narcotic medications. R6's Safety Events- Medication Error report dated 2/2/25, indicated R6 received R229's medications. […]

• Actual harm, isolatedF684Jun 8, 2021

  Based on observation, interview and document review, the facility failed to ensure indwelling catheter management and skin assessments were completed to prevent erosion (tearing) of the penile urethral (opening for urine to pass out of body) for 1 of 3 resident (R4), whom had an indwelling urinary catheter. This caused actual harm for R4. Findings include: R4's Face Sheet printed 6/8/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's admission Minimum Data Set, dated dated dated [DATE], indicated R4 was admitted in 4/21, had severe cognitive impairment, required extensive assist of two staff for toileting, bed mobility and transfers with Care Area Assessment triggered for urinary incontinence and indwelling catheter. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF725Apr 18, 2024

  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. […]