F-F725 Sufficient Nursing Staff: Call Light Times included columns titled date, resident, shift being audited, were call lights answered timely, does resident have any concerns with call light times, and comments. Completed audit sheets were dated from 2/25/25 through 5/7/25.
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.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 245255 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867 During an interview on 5/15/25 at 8:15 a.m., the director of nursing (DON) stated she was aware call lights were an ongoing problem because of concerns and reports from residents. The DON stated data regarding Level of Harm - Minimal harm or call light times was monitored through the audits and resident concerns, like grievances filed. The DON potential for actual harm reviewed the facility's call light logs dated 2/25/25 through 5/7/25. She identified some audits were marked see attached and did not specify if the light was answered timely or the resident had concerns, some audits Residents Affected - Many stated lights were answered timely but included call light logs with times that did not meet her expectations for timeliness, and some audits were not completed fully. The DON stated the audits were not complete or accurate, did not specify what constituted timeliness, and did not include analysis of the data. The DON was unable to articulate how the facility was analyzing data and monitoring the call light times when the data collected was not complete or accurate and stated we weren't doing that effectively. She noted call light data came from audits and grievances and would be analyzed prior to and reviewed at QAPI meetings. She confirmed the QAPI meeting slide for plans of correction did not include data. After reviewing the call light audit sheets, she stated the data in the audits identified ongoing concerns and noted I don't see inclusion or analysis of the data or development of an improvement plan in the QAPI committee meetings. She further noted there was no analysis of the causal factor of action plan that I'm aware of and identified the administrator as the person who had been more involved and would know more.
During and interview on 5/15/25 at 3:39 p.m., the administrator stated call lights were identified as an issue and the facility was cited for this in January. The plan to monitor and ensure compliance was nurse managers completing call light audits weekly, though she stated the audits were not complete or accurate.
The administrator stated audits were analyzed by the nurse managers completing them, the DON, and herself and they did not identify the call light times as continued issue through the audits but they should have. She stated call light time data had not been analyzed in QAPI and a causal analysis had not been completed. The administrator stated the QAPI committee meeting showed the audits were being done and identified the number of related grievances, but we need to do more a deep dive into the why's behind them.
She confirmed there was no action plan for process improvement based on the data and no measurable goal for call light times. She stated, the goal was 15 minutes, but it is not identified.
Facility policy titled Call Lights - Call System Activation and Response dated 5/28/24, included Call light response times are reviewed as part of the QAPI program.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 245255 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867 Facility policy titled Quality Council (Quality Assessment and Assurance Committee) undated, indicated the facility had a Quality Council. The Quality Council assumes responsibility and oversight for services related Level of Harm - Minimal harm or to resident safety, health outcomes, resident autonomy, choice, quality of care, as well as customer potential for actual harm satisfaction, regulatory compliance, and related performance improvement. The community will develop a plan to promote excellence in quality of care, quality of life, resident choice and person directed care. To Residents Affected - Many accomplish this all employees are empowered to participate in ongoing QAPI efforts which support our mission. The Quality Council will collect and utilize data related to the unique characteristics and needs of
the patients, focusing on high risk, problem prone, and high-volume areas to develop their annual QAPI plan.
The Quality Council serves as the Community's Quality Assessment and Assurance (QAA) Committee with oversight of the Quality Assurance and Process Improvement (QAPI) program. Procedure included, The Quality Assessment and Assurance committee Plan describes the process for identifying and correcting quality deficiencies and includes: a) Tracking and measuring performance; b) Establishing goals and thresholds for performance improvement; c) Evaluation of the care and services provided; d) Identifying and prioritizing quality deficiencies and opportunities for improvement; e) Systematically analyzing underlying causes of systemic quality deficiencies; f) Developing and implementing corrective action or performance improvement activities; g) Monitoring and/or evaluating the effectiveness of corrective action and performance improvement activities and revising as indicated; h) The QAA plan will be reviewed annually and with any significant change to the community.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 245255