Cerenity Care Center on Humboldt

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain a clean, homelike environment for 2 of 2 residents (R45, R2) who received nutrition via tube feeding.

Inspectors wroteBased on interview and document review, the facility failed to ensure an antipsychotic medication (medication that works by changing the effects of chemicals in the brain) had a qualifying diagnosis to support its use for 1 of 5 residents (R8) reviewed who required antipsychotic medicationsFindings include:R8's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R8 did not hallucinate, have delusions, behaviors, wander or reject care during the assessment period. R8 took an antipsychotic medication in the last seven days, and an indication was noted. R8's psychotropic drug use care plan dated 2/27/26, identified psychotropic medication was in use, to administer medications per MD (medical doctor) order, monthly medication record review by pharmacist, and monitor for target behaviors daily. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the manufacturer's recommended sling size was used for 1 of 1 resident (R79) reviewed for mechanical lift transfers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure administration of tube feeding formula according to provider orders for 1 of 1 resident (R45) reviewed for tube feeding.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R44) reviewed for respiratory care.

Inspectors wroteThe facility failed to ensure new medication orders were transcribed correctly to ensure accurate medication administration for 1 of 1 resident (R79) who was reviewed for recent medication changes.

Inspectors wroteBased on interview and document review, the facility failed to ensure consultant pharmacist recommendations were followed up timely for 1 of 5 residents (R8) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to implement enhanced barrier precautions (EBP) for 2 of 2 residents (R19 and R2) observed for EBP.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of maltreatment to the state agency within two hours after the allegation was made for 1 of 1 resident (R2) reviewed for reporting of alleged violations of maltreatment. R2 reported the allegations of maltreatment to dietary aide (DA)-A on 11/11/2025 and the facility did not report the allegations to the state agency.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to excessively long call light response times by developing and implementing action plans for process improvement identified to be a current concern with past identified non compliancy. This had the potential to affect all 81 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and failed to identify and report medication errors for 2 of 3 (R1, R2) residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide adaptive eating utensils according to the care plan for 1 of 1 resident (R7) reviewed for nutrition.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 2 of 3 residents (R2, R3) reviewed for documentation.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance they needed (R127, R35, R281, R11, R25, R59) for 6 of 7 residents reviewed for staffing needs. This had the potential to affect all 85 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure expired food items were removed from service, food items were labeled and dated, and food was stored in a manner to prevent cross contamination from resident care items. Furthermore, the facility failed to ensure follow up and maintenance of a leaking refrigerator, routine maintenance of the dishwasher and overall cleanliness of the kitchen was maintained.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure transmission-based precautions (TBP) were followed for 1 of 1 resident (R38) who required TPB during medication administration and failed to ensure a glucose meter was disinfected per manufacturer's guidelines after resident use for 1 of 1 residents (R31) observed for glucose monitoring. Furthermore, the facility failed to ensure resident clothing was transported in a manner to ensure cleanliness and protect from dust and soil during transport. This had the potential to impact all residents residing on the 3rd floor and who the facility provides laundry services for.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dignity was maintained for 2 of 4 residents (R11, R277) reviewed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R10, R278, R59) reviewed who had medications in their rooms.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure timely assistance with toileting for 2 of 2 (R50, R127) residents.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure symptoms of loose stools was acted upon and assessed to determine what, if any interventions were needed to promote appropriate bowel management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions necessary to maintain continence for 1 of 1 resident (R72) reviewed for bowel and bladder.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure pain medications were administered timely in accordance with physician's orders and care plan for 1 of 1 residents (R25) reviewed for pain management. Findings Include: R25's minimum data set (MDS) dated [DATE], indicated R25 had a brief interview for mental status (BIMS) of 15, showing intact cognition. R25 had a diagnosis of hypertension, diabetes, arthritis, and chronic obstructive pulmonary disease (COPD). R25 receives both scheduled and as needed pain medication related diagnosis of chronic pain syndrome and non-displaced oblique fracture of the shaft of the right fibula. [...]

Inspectors wroteBased on interview and document review, the facility failed to assess trauma history and identify potential triggers for 1 of 1 resident (R54) who had a diagnosis of post traumatic stress disorder (PTSD).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure call lights were accessible for 1 of 1 resident (R9) reviewed.

Inspectors wroteBased 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. The facility had implemented corrective action on 12/3/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to notify family and physician regarding a resident change in condition for one of one resident (R1) reviewed when R1's venous ulcer wound worsened requiring hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to reduce the risk of harm for one of one resident (R2) reviewed accidents and hazards. R2 required the use of an EZ Stand and facility staff were using a large sized harness. The EZ Stand manufacturer guidelines state a large harness fit a person between one hundred ninety pounds to three hundred twenty pounds. R2 exceeded the weight limit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an EZ Stand was maintained in accordance with manufacturer guidelines for one of one resident (R2) reviewed for EZ Stands. It is unknown when R2's EZ Stand was last maintained due to no record of it being maintained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow resident meal tickets , provide palatable meals, and provide meals to meet the needs of the residents for four of four residents (R2, R4, R5, R6) reviewed for meals and food . R2 requested a butterscotch square and French bread for lunch but received chocolate cake and no bread. R4, R5, and R6 were not able to finish their lunch due to the food either being too dry or could not eat the lunch due to not having teeth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and home like environment for 10 of 25 residents (R12, R13, R4, R5, R6, R7, R8, R9, R10, R11) reviewed and all independently mobile residents on the 3rd floor when concerns related to resident bathrooms and flooring, cleaning practices and cleaning product storage were observed.

Inspectors wroteBased 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.

Inspectors wroteBased 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. R1 had a right knee open reduction dislocated hinged total knee arthroplasty revision on 6/20/24 with confirmation of infectious bacteria: [...]

Inspectors wroteBased on interview and record review the facility failed to accurately assess 1 of 3 residents (R1) reviewed upon admission to the facility. R1 was admitted with two pressure ulcers, a deep tissue injury and a shearing wound that the facility did not assess or create inventions for during his stay at the facility. R1's hospital discharge orders dated 6/25/24 indicated R1 had: -A Stage 3 (an injury that extends through the skin into deeper skin and fat but does not reach muscle tendon or bone) pressure ulcer on the dorsum (upper surface) of his second right toe. R1 had this pressure injury since 1/6/23. -A dermatologic condition of his right foot since 1/6/23 -Incision on the anterior portion of his right knee since 6/20/24 -A Stage 4 (an injury that extends to the muscle, tendon, and bone) pressure injury on the dorsum of his third right toe since 6/21/24. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to serve food at a palatable temperature to 4 of 4 residents (R4, R9, R11, R10) reviewed for dietary and nutrition.

Inspectors wroteBased on observation and interview the facility failed to provide a clean, safe and home-like environment for 3 of 3 residents (R1, R4, R11) reviewed for a clean environment on the 4th floor and [NAME] end.

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure baths were given as ordered for 2 of 3 residents (R4, R10) who needed assistance with activities of daily living (ADLs).

Inspectors wroteBased on interview and document review the facility failed to ensure medications were appropriately transcribed into the electronic health record (EHR), ordered timely and correct medication dosages were administered in accordance with physician orders for 1 of 1 residents (R3), reviewed for missed medication errors.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 3 of 3 kitchenettes were cleaned,including the cleaning of the kitchenette refrigerators and also failed to monitor refrigerator temperatures daily to maintain food safety. This had the potential to affect all residents who resided at the facility. Findings Include: During observation and record review on 11/30/23 at 9:34 a.m., the second-floor kitchenette countertop was noted with debris and dust buildup. The refrigerator freezer had spilled brownish matter frozen to the bottom lining of the freezer. The refrigerator had brown buildup and dark brownish stains in the refrigerator shelving and door compartments. During record review, the refrigerator temp log on the door of the refrigerator was dated 5/23 and was missing several days of documented temperature checks for May 2023. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure catheter drainage bags were properly cleaned and stored in accordance with professional standards of practice for 1 of 1 resident (R38) reviewed for catheters.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor a resident (R59) with involuntary muscle movements who was taking antipsychotic medications. R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of alzheimer's disease (early onset), dementia with other behavioral disturbance and adjustment disorder with anxiety. It further indicated R59 required total dependence with transfers, required extensive assistance with all other activities of daily living (ADL), and received an antipsychotic 7 out of 7 days in the look back period. R59's physician's orders dated 11/03/22, indicated quetiapine tablet 50 milligrams by mouth, three times a day (8:00 a.m., 12:00 p.m., 7:00 p.m.) for agitation. [...]