Cerenity Care Center White Bear Lake

Inspectors wroteBased on interview and record review, the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) and activate the emergency response system (EMS) when 1 of 1 residents, with a full code status (when a resident's heart stops being (SP) the medical team uses all available lifesaving measures) was found unresponsive. This resulted in an Immediate Jeopardy (IJ) citation when licensed practical nurse, (LPN)-A, was notified by nursing assistant (NA)-A that R1 was unresponsive. LPN-A immediately checked on R1 finding R1 cool to the touch, without pulse and was not breathing. LPN-A failed to assess R1 for irreversible signs of death to determine and if necessary, perform CPR.The immediate jeopardy began on [DATE] when LPN-A failed to assess R1 for irreversible signs of death and did not initiate CPR immediately. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained by not providing a catheter bag cover for 1 of 1 resident (R146) reviewed for catheters.

Inspectors wroteBased on interview and document review, the facility failed to ensure a care conference was provided for 1 of 1 resident (R130) reviewed for care conferences.

Inspectors wroteREVIEWED LNBased on interview and document review the facility failed to ensure an as needed (PRN) antipsychotic medication (medications to treat psychosis related conditions) was prescribed for only 14 days and failed to ensure staff documented use of nonpharmacological interventions used prior to administration of PRN antipsychotic medication 1 of 2 residents (R117) who received PRN antipsychotic medications.

Inspectors wroteR677Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene for nail care was provided for 1 of 1 resident (R6) reviewed for activities of daily living (ADLs) and were dependent on staff for their care.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident attended a scheduled urology appointment for 1 of 1 residents (R146) reviewed for appointments.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a mechanical lift was sanitized between use and furthermore, the facility failed to ensure personal protective equipment (PPE) was donned prior to a transfer for 1 of 1 resident (R5) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper self-administration of insulin for 1 or 1 resident (R87) reviewed for self-administration of medications (SAM).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper nail care for 1 of 1 resident (R95) reviewed for activities of daily living.

Inspectors wroteBased on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted for 1 of 1 resident (R52) reviewed for the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure insulin was administered in accordance with professional standards of practice for 2 of 3 residents (R100, R51) observed for medication administration. This constituted three (3) errors out of 33 opportunities for a medication error rate of 9.09 % (percent).

Inspectors wroteBased on observation, interview and document review the facility failed to follow infection control standards of practice for incontinence cares and/or contact precautions for 2 of 2 residents (R40 and R364) reviewed for activities of daily living (ADLs)

Inspectors wroteBased on observation, interview, and document review, the facility failed to perform comprehensive skin assessments and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 1 resident (R100) reviewed for pressure ulcers. This resulted in harm for R100.

Inspectors wroteBased on interview and document review, the facility failed to have a method or system in place to ensure the facility offered or provided 3 of 5 residents (R9, R92, R103) updated vaccines to residents per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 117 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 2 of 2 residents (R92, R24) observed with medications at the bedside.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident current wishes for resuscitation status were accurately documented in the medical record for 1 of 2 residents R19 reviewed for advanced directives.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan to include assessed risks and interventions with skin care to reduce the risk of complication for 1 of 3 residents (R36) with pressure ulcers reviewed for care planning. In addition, the facility failed to develop a comprehensive person-centered care plan for psychotropic drug use for 1 of 5 residents (R21) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a walking program was maintained for 1 of 1 resident (R51) reviewed for ambulation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement care plan interventions for 1 of 1 resident (R263) reviewed with a history of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate collaboration with providers and pharmacy in the transcription of orders for 3 of 3 (R7, R56, and R66) reviewed for medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities involving 1 of 5 residents (R7) who were observed during medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 3 of 3 residents (R16, R19, R96) reviewed for dining services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper glove use for 1 of 2 resident (R103) reviewed for blood sugar checks and failed to ensure appropriate hand sanitization between glove use for 1 of 2 resident (R100) reviewed during incontinence cares.