Cerenity Care Center On Humboldt

During an interview on 5/14/25 at 5:22 p.m., the administrator stated each nurse manager had been completing audits each week on a variety of shift.

The administrator stated currently one resident and one shift was being audited each week, and the resident and shift had been picked at random.

The administrator stated she had not heard of any concerns identified on the audits but had reviewed call light logs requested by surveyors and the data reflected in the call light logs did not align with what was recorded on the audit sheets.

The administrator stated no specific direction was given to nurse managers when completing the audits, such as what constituted answering a call light timely, and they just followed the prompts in the column titles.

She noted the QAPI committee met monthly and reviewed reportable incidents from the prior month, current plans of correction being worked though, admission data, quality improvement program data, return to hospital data, medication errors, skin issues, falls, behavior management, concerns from the prior month, nutrition and weight data, human resources data, and anything else relevant at the time.

The administrator stated call light logs have not been included in QAPI and noted they were listed under the current audits the facility was doing and there hasn't been concerns in the actual audits.

The administrator stated call lights had not been identified as on ongoing concern.

245255

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 245255 B.

Wing 05/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107