Cerenity Care Center On Humboldt
Cerenity Care Center on Humboldt in SAINT PAUL, MN — inspection on March 5, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During observation on 3/2/26 at 4:49 p.m., R2 had tube feeding formula hanging, attached to R2 via G-tube and running.
The base and the pole that held the bag of tube feeding formula and water flush, as well as the enteral feeding pump had copious amount of light brown drips and large brown spots of dried liquid on it.
During observation on 3/3/26 at 11:20 a.m., R2 was in bed with his tube feeding attached and running and still had copious amounts of dried beige colored substance on the base of the tube feeding pole.
During interview on 3/3/26 at 11:39 a.m., housekeeper (H)-B stated they cleaned R2 room, however, housekeeping was not responsible for cleaning R2's tube feed pole or machine. H-B verified there was a lot of brown dried liquid all over the pole and the base of the pole.
The housekeeping cleaning list did not have tube feeding pole listed to clean it.
During interview on 3/3/26 at 11:53 a.m., registered nurse (RN)-F stated there was a large amount of dried formula on the machine, pole and base.
Furthermore, RN-F had administered R2's medication this am, however, did not clean the pole or machine.
During interview on 3/3/26 at 11:35 a.m., RN-A stated they would expect nursing to wipe up any formula at the time of the spill and that housekeeping could also share the responsibility if a dirty pole was seen when cleaning the resident room. RN-A further stated they would expect residents to have a clean, homelike environment.
During interview on 3/3/26 at 3:37 p.m., director of nursing (DON) stated nursing should clean the tube feeding poles when a spill occurs, and that housekeeping could also clean the poles as needed.
DON stated would expect residents' dignity to be considered and should and a clean homelike environment provided.
Facility policy titled Monitoring Residents Receiving Enteral Feedings dated August 2019, directed the nursing staff to be responsible for the administration of enteral feedings and all feeding equipment.
Facility policy titled Resident Care Equipment dated 1/2024, directed staff to ensure IV poles were cleaned when soiled by either housekeeping or nursing.
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
During an email on 3/5/26 at 1:09 p.m., the CP identified she was not available for phone calls.
The CP's email response identified R8's' psychiatric services were managed by ACP. In situations where outside psychiatric providers oversee psychotropic management, the facility appropriately forwards consultant pharmacist recommendations to the prescribing provider by fax for review.
The facility's Psychotropic Medication Use policy dated 9/7/23, directed the DON to implement the policy to ensure psychotropic medications were ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record.
Additionally, the nursing associates would collaborate with the medical providers to ensure the lowest possible dosage was given for the shortest period.
The policy lacked the process to review qualifying diagnoses for antipsychotic medications.
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
During an observation and interview on 3/2/26 at 3:24 p.m., nursing assistant (NA)-A positioned an EZ Lift brand full body sling with maroon straps under R79 while he sat in his wheelchair. NA-A had not looked at the sling label for size, and positioned the sling behind R79's back, brought the leg straps under R79's legs, crossed the straps, connected the sling to EZ Lift model 798 (full body mechanical lift) and connected the longer lower loop to the EZ Lift hooks. NA-B connected the upper loops using the lower strap to the EZ lift hooks.
NA-A raised R79 in the sling out of R79's wheelchair, pushed the lift over to the bed, lowered R79 to the bed and NA-A and NA-B lowered the sling to the bed and removed the sling from under R79.
During the transfer R79's body was tilted to the right, instead of straight up and down, and his left hip and buttocks hung down through the sling seat opening area.
When asked what sling size was used, NA-A picked up the sling that was removed and read the label which read size large. NA-A stated he should have checked the sling size before completing the transfer. NA-A removed the sling from R79's room as it was soiled.During a follow up interview on 3/2/26 at 5:38 p.m., NA-B stated staff should reference the care card for mechanical lift sling sizes. NA-B presented the care card which specified a medium sling should have been used. NA-B stated sometimes if a resident had a shower and the sling got wet, staff would have to use what was available. NA-B confirmed she was with Na-A during the transfer, and the sling size was not checked.
During an interview on 3/2/26 at 5:43 p.m., registered nurse (RN)-B stated mechanical lift sling size was the responsibility of the managers and the staff should reference the resident care cards. RN-B presented R79's care card which identified he needed a medium body sling. RN-B stated she would look for a medium sling, since NA-A brought the sling to the laundry and no sling was currently available.
During an interview on 3/4/26 at 2:38 p.m., the director of nursing (DON) stated therapy would establish sling size for residents and communicate with the managers so the care cards could be updated.
The purpose of appropriately sizing a sling was to prevent accidents due to unsafe equipment.
During an interview on 3/5/26 at 11:53 a.m., the physical therapist (PT) verified R79 should use a medium size sling to ensure transfers are stable.The EZ Way Sling Size Chart (form #2-150) dated 9/13/24, identified a large sling (burgundy straps) should be used for resident weight of 190 to 330 pounds and maximum distance from tailbone to base of neck of 26 inches, and medium sling size (beige straps) should be used for resident weight of 90 to 220 pounds and maximum distance from tailbone to base of neck 24 inches.The facility's undated policy titled Using a Mechanical Lift, identified a resident needed to be measured for proper sling size and purpose according to manufacturer's instructions and to double check the sling and machine's weight limit against the resident's weight.
After placing the sling under the resident, visually check the size to ensure it is not too large or too small.
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
expect nurses to have changed the rate with the most recent administration.A facility policy titled
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
During interview on 3/2/26 at 1:51 p.m., licensed practical nurse (LPN)-C stated oxygen tubing and bubbler were changed once a week by the nurse.
LPN-C stated she forgot to change R44's bubbler yesterday (3/1/26).
Further, she verified she should not have signed it off as being completed since she did not complete the task outlined on the TAR.
LPN-C confirmed R44's oxygen tubing was not dated, and the bubbler was dated 2/15. LPN-C could not confirm when the tubing had last been changed and could not explain why the bubbler was signed off as changed on 2/22/26 and still had the 2/15 date on it.
During interview on 3/3/26 at 2:47 p.m., registered nurse (RN)-A expected nurses to follow orders as written and would not expect nurses to sign off medication administrations or treatments if they were not actually completed. RN-A further stated R44's oxygen tubing and bubbler should be changed weekly to prevent any respiratory infections.
During interview on 3/3/26 at 3:37 p.m., director of nursing (DON) stated staff were expected to follow provider orders as written and not sign off items on the medication administration record (MAR) or TAR if not actually completed.
Facility policy Cleaning of Oxygen Equipment dated June 2017, identified purpose to reduce the risk of infections and directed staff to replace oxygen tubing and humidifier bottle once a week and to use tape to place date and initials on tubing and bottle when replaced.
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
error was not serious because after the medication was discontinued, only one extra dose was
returned from the emergency department. RN-C stated she entered the new order for Keppra into
at 12:22 p.m., the director of nursing (DON) stated he expected two nurses to verify new medication orders for accuracy.
New orders for a resident should be reviewed and implemented as soon as possible.
The DON stated the order was missed on the AVS at the time of R79's return, and subsequent nurses had not reviewed the original AVS.A medication transcription policy was not obtained on survey.
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Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
providers into consideration, while continuing to follow up as needed to support appropriate
the medical provider to treat a specific condition as diagnosed and documented in the medical record.
lowest possible dosage was given for the shortest period.
The policy lacked the process to review qualifying diagnoses for antipsychotic medications.The facility's Consultant Pharmacist Services Provider Requirements dated 12/17, indicated a written or electronic report of findings and recommendations would be completed monthly and the facility had a process to ensure the findings were acted upon.
245255 03/05/2026
Cerenity Care Center on Humboldt 512 Humboldt Avenue Saint Paul, MN 55107
hemodialysis catheters, feeding tubes and indwelling urinary catheters.
High-contact resident care
intended to be used for the duration of a resident's stay.