Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cerenity Care Center White Bear Lake during CMS and state inspections, most recent first.
A resident with a full code order and intact cognition was found unresponsive and not breathing by a NA, who promptly notified an LPN. The LPN confirmed the resident was unresponsive, without a palpable radial pulse, and noted cool skin on the forehead but did not fully assess the body, verify code status, announce a code blue, or initiate CPR or EMS activation. Instead, the LPN called another LPN to "look at something" and waited several minutes. When the second LPN arrived, she entered the room, verified the full code status, noted the resident was not breathing but still warm with no rigor mortis, and immediately initiated CPR while directing staff to call 911, announce a code blue correctly, and obtain the AED and crash cart. This sequence of inaction and delay by the first LPN, contrary to facility policy requiring immediate CPR and EMS activation for unresponsive full code residents, led to an Immediate Jeopardy deficiency.
A resident with an indwelling catheter, intact cognition, and assistance needs for mobility and toileting had a urine bag left exposed in bed and in a wheelchair despite an order to keep it covered. The resident stated she did not want others seeing her urine, and nursing staff and the DON confirmed catheter bags should be covered for dignity.
Failure to Provide Documented Care Conference: A resident who was cognitively intact and discussing discharge planning did not have a documented care conference after the initial meeting. The chart showed only one care conference, while the resident stated she had not had a care conference after moving to LTC. The SW and DON verified no additional care conferences were documented despite the MDS-based scheduling process.
A resident with severe cognitive impairment and dementia with severe anxiety received PRN quetiapine for behavior issues, but the order had no end date and the record did not show nonpharmacological interventions were tried before administration. Staff, the DON, and the CP stated PRN antipsychotic orders should be limited to 14 days and that behaviors and interventions attempted should be documented, consistent with the facility’s psychotropic medication policy.
A resident with hemiplegia, moderate cognitive impairment, and dependence for grooming did not receive routine nail care despite repeated requests. Staff told the resident that a nurse or doctor had to cut the nails, while documentation stated nail care was not necessary after a shower. On observation, the resident’s fingernails were long, jagged, and sharp, and clippers were found on the floor in the room. An RN stated a doctor did not need to cut the nails, and the DON said nail care was to be checked weekly on bath/shower day.
A resident with intact cognition and an indwelling Foley catheter missed a scheduled urology follow-up despite discharge orders stating the catheter should remain in place until that visit. The resident said she was unaware of the appointment, the family was not contacted for transportation, and staff could not explain why the appointment was missed. The HIT, NP, RN, and DON each described different roles in appointment management, but no documentation showed the resident attended the urology visit or that it was canceled.
Staff failed to follow EBP and infection control during transfers for two residents with wounds. Two NAs used the same Hoyer lift to transfer one resident and then another resident with active wounds, but did not wipe down the lift between uses and did not don gowns or gloves before the transfers. The resident’s room had EBP signage, and staff interviews confirmed the lift should have been sanitized and PPE worn for high-contact care activities.
A resident with impaired vision and a history of non-compliance was allowed to self-administer insulin but failed to prime the insulin pen, leading to incorrect dosages. Despite being educated on self-administration, the resident did not follow the necessary steps, and the facility lacked a specific policy on priming insulin pens.
A resident with moderately impaired cognition and lumbar stenosis did not receive proper nail care as outlined in their care plan. Observations showed the resident's nails were approximately 1 inch long, and they expressed a desire to have them cut. Staff interviews revealed inconsistencies in nail care responsibilities, with nursing assistants and nurses having different roles depending on the resident's diabetic status. The facility's policy required weekly nail care, but documentation was lacking, indicating a failure to adhere to the policy.
The facility failed to attempt a gradual dose reduction (GDR) for a resident on psychotropic medications due to an IT glitch that prevented the receipt of recommendations from the consultant pharmacist. Additionally, the facility did not obtain informed consent for the use of Depakote, a psychotropic medication, for a resident with severe cognitive impairment, as required by policy.
Two residents with diabetes received insulin injections without proper needle priming, leading to a medication error rate of 9.09%. LPNs failed to follow manufacturer's instructions, and the facility lacked a specific insulin pen policy.
The facility failed to follow infection control standards for two residents. A resident requiring incontinence care was not provided proper hand hygiene by a nursing assistant, who used the same gloves throughout the care process. Another resident, needing contact precautions due to an ESBL-resistant infection, was assisted by a physical therapist assistant who did not wear the required gown and gloves. Both staff members acknowledged their oversights, and the facility's infection preventionist emphasized the importance of adhering to protocols.
Failure to Immediately Initiate CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to immediately initiate CPR and activate EMS for a resident with a documented full code status who was found unresponsive. The resident had diagnoses including enterocolitis due to Clostridium difficile, a non-pressure ulcer of the left foot, and peripheral vascular disease, and required partial to moderate assistance with grooming and transfers. A physician order indicated the resident was full code, and the resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. According to the report, around midnight a nursing assistant observed that the resident’s chest was not rising, the resident did not respond to attempts at arousal, and appeared not to be breathing. The NA immediately notified an LPN, who went to the room and found the resident in bed with the head of the bed elevated and the head tilted to the right. The LPN was unable to locate a radial pulse, observed no chest rise, and noted the resident’s forehead felt cool. The LPN did not pull back the covers to further assess the resident, did not verify the code status, did not announce a code blue, and did not give instructions to the NA. Instead, the LPN called another nurse to come to the unit, stating that before anything could be done, a second nurse was needed, and then waited approximately five minutes for that nurse to arrive. When the second LPN arrived, she found the first LPN and the NA standing outside the resident’s room. Upon entering, she assessed that the resident was not breathing, checked the code status, and determined the resident was full code. She noted the resident’s body was warm and that rigor mortis had not set in, and immediately initiated CPR, directing staff to call 911, announce a code blue, and obtain the AED and crash cart. The facility’s policy specified that for an unresponsive resident with a full code order, EMS should be activated immediately and CPR initiated unless there were obvious signs of clinical death such as rigor mortis, dependent lividity, decapitation, transection, or decomposition, or other specified exceptions. The failure of the first LPN to promptly assess for irreversible signs of death and to immediately initiate CPR and activate EMS for this full code resident resulted in an Immediate Jeopardy citation.
Removal Plan
- Completed an investigation and identified that a nurse failed to initiate CPR immediately on a full code resident found unresponsive.
- Conducted a root cause analysis and identified that CPR was not initiated per facility policy and that delegation of duties during the code situation did not occur.
- Placed the involved nurse on leave pending the investigation and terminated employment.
- Educated staff on the processes and procedures to follow when a resident is found unresponsive.
- Audited and verified all residents’ code statuses as correct.
- Reviewed facility policies.
Exposed Catheter Bag Not Covered for Resident Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity by not providing a catheter bag cover for R146, who had intact cognition, required partial/moderate assistance with mobility and toileting, and had an indwelling catheter. R146's diagnoses included acute kidney failure, an unspecified open wound to the right hip and abdominal wall, and cellulitis. The resident's Urinary Incontinence and Indwelling Catheter Care Area Assessment indicated the resident required foley catheter care and was at risk for complications and UTI. The care plan identified an ADL self-care deficit and need for assistance with ambulation, transferring, mobility, and toileting. A provider order directed staff to ensure a catheter cover or pant leg was in place so the urine bag would not be visible. During multiple observations, R146's urine catheter bag was seen exposed while the resident was in bed and while seated in a wheelchair, including when the resident was sleeping and when therapy staff entered the room. The resident stated she did not want everyone seeing her urine and said staff had brought meals, therapy, and others into the room while the bag was exposed. Nursing staff confirmed that catheter bags should be covered to maintain dignity, and the DON stated urine bags should be covered for dignity. Facility policy stated the facility acts to protect and ensure the rights of residents.
Failure to Provide Documented Care Conference
Penalty
Summary
The facility failed to ensure a care conference was provided for one resident who was reviewed for care conferences. The resident’s quarterly MDS indicated she was admitted on 7/30/25 and was cognitively intact, with no hallucinations or delusions. Social service notes documented that she wanted assisted living placement but was still pending medical assistance, and a care conference was scheduled for 8/8/25 to discuss discharge planning and recommendations. A social service note later documented that a care conference had occurred on 8/8/25, but the resident’s medical record did not contain information showing any care conference after that date. Additional documentation showed a nursing note on 8/18/25 indicating the resident was alert and oriented and had new orders to discharge to LTC, and a social service note the same day documented discussion of discharge planning and the resident’s plan to remain in the facility’s LTC unit until medical assistance was approved, then transfer to assisted living. However, the care conference form saved on 12/11/25 listed the last care conference as 8/8/25 and the next one as 11/9/25, with no record of a conference after 8/8/25. During interview, the resident stated she had not had a care conference and had moved to the LTC unit in August. The SW and DON both stated care conferences were coordinated after the MDS process, but they verified that only one care conference was documented and no additional conferences were found in the record.
PRN Antipsychotic Order Lacked 14-Day Limit and Required Documentation
Penalty
Summary
The facility failed to ensure that an as needed (PRN) antipsychotic medication was prescribed for only 14 days and failed to ensure staff documented nonpharmacological interventions used before giving the medication for one resident with severe cognitive impairment and diagnoses of dementia with severe anxiety. The resident’s record showed an order for quetiapine 50 mg every 6 hours as needed for psychosis and dementia with anxiety that had no end date. The resident received PRN quetiapine multiple times in November and December 2025 for behavior issues, but the medical record did not show that non-drug interventions were provided before administration. The resident’s care plan directed staff to monitor target behaviors and document each shift, and a separate order required monitoring for behaviors such as changes in sleep pattern, agitation, delusions, and hallucinations, with documentation of behaviors and non-drug interventions when observed. During interviews, nursing staff stated that PRN antipsychotic medication orders should be limited to 14 days and that the reason for use and nonpharmacological interventions should be documented. The DON and clinical pharmacist also stated that PRN antipsychotic orders were expected to be limited to 14 days and that behaviors and interventions attempted should be documented. The facility policy titled Psychotropic Medication Use likewise directed PRN antipsychotic orders to be limited to 14 days and required documentation of target behaviors and nonpharmacological interventions.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine personal hygiene and nail care were provided for a resident who was dependent on staff for assistance with ADLs. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, moderate cognitive impairment, and required partial/moderate assistance with personal hygiene. The care plan identified an ADL self-care deficit with grooming and that the resident required assistance from one staff member. However, weekly skin check documentation stated that nail care was not necessary after a shower. During observation and interviews, the resident reported repeatedly asking staff to cut his fingernails and being told that a nurse or doctor had to do it. The resident stated the nails were long and sharp, and a family member had tried to cut them but was concerned about injuring the curled fingers on the resident’s left hand. On later observation, the resident’s fingernails on both hands were about 1/4 inch long with jagged, sharp edges, and the resident again stated he had tried to cut them himself and had asked staff again. Fingernail clippers were found on the floor under the television in the resident’s room. A CNA stated fingernails were cut on bath day or sometimes on weekends and there was no risk in cutting them, while an RN stated it was not necessary for a doctor to cut the nails and confirmed the clippers were on the floor. The DON stated nail care was to be checked and completed weekly on bath/shower day and that nail care was important for dignity and infection control.
Missed Urology Appointment for Resident With Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident attended a scheduled urology appointment. R146 had intact cognition, required partial/moderate assistance with mobility and toileting, and had an indwelling Foley catheter. The resident’s diagnoses included acute kidney failure, an unspecified open wound to the right hip and abdominal wall, and cellulitis. The resident’s Urinary Incontinence and Indwelling Catheter Care Area Assessment indicated the resident required Foley catheter care and was at risk for complications and UTI. Hospital discharge orders stated the resident had a follow-up appointment with MN Urology and that the Foley catheter should remain in place until that appointment. The resident later had a provider order indicating the patient should reach out to the urologist to see if the Foley catheter could be removed. During interviews, the resident stated she was not aware of any upcoming urology appointment and did not remember seeing a urologist since admission. The NP stated she was not sure about the appointment and that the facility scheduler handled those arrangements. The HIT stated she reviewed admission orders and handled referrals and transportation arrangements, but could not explain why the resident missed the appointment and did not remember making arrangements for it. The PSR confirmed the resident was scheduled for the urology appointment but was a no-show, and the family member stated they were not aware of the appointment and were not contacted for transportation arrangements. The RN stated the HIT was responsible for managing appointments and transportation, and the DON stated residents were expected to attend scheduled appointments with staff assistance for transportation, with documentation if an appointment was canceled. No facility appointment management policy was provided.
Failure to Follow EBP and Sanitize Mechanical Lift Between Resident Transfers
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during transfers involving two residents with enhanced barrier precautions (EBP). One resident had moderate cognitive impairment, used a wheelchair, and required two staff assistance with a Hoyer lift for transfers. The other resident had substantial assistance needs, two unstageable pressure injuries, and active orders and a care plan indicating EBP due to wounds to the leg and spine, with interventions requiring staff to apply gloves and gowns prior to high-contact care activities and to post precaution signage outside the room. During observation, nursing assistants used the same mechanical lift to transfer the first resident from bed to chair and then moved the lift to the second resident’s side of the room. The lift had a pocket for Super Sani-Cloths, but neither nursing assistant wiped down the lift after use with the first resident before transferring the second resident. The nursing assistants also did not don gowns or gloves before assisting with the transfers. The second resident had a dressing to the right lateral leg, and the lift was later brought out of the room and re-entered without being wiped down. During interviews, the nursing assistants stated they had been instructed to clean the lift after every resident use, and one acknowledged that EBP required gowns and gloves for residents with wounds and that they did not wear PPE or clean the lift between residents. Other staff, including an RN, the infection preventionist, and the DON, stated staff should don gloves and gowns during transfers when a resident had a wound and that mechanical lifts should be sanitized between residents. The facility’s policies on standard precautions and enhanced barrier precautions stated reusable equipment should be cleaned before use on another client and that EBP requires gowns and gloves during high-contact resident care activities, including transferring and wound care.
Failure in Insulin Self-Administration Process
Penalty
Summary
The facility failed to ensure proper self-administration of insulin for a resident, identified as R87, who was reviewed for self-administration of medications. R87 was cognitively intact and independent with most activities of daily living, but had impaired vision and a history of non-compliance with medications. The resident's care plan indicated that R87 was capable of self-administering insulin, and the medication administration record allowed for insulin to be kept in the room for self-administration. However, during observations, it was noted that R87 did not prime the insulin pen before administration, which is a necessary step to ensure the correct dosage is delivered. Interviews with nursing staff revealed that R87 was educated on insulin self-administration and was expected to perform a return demonstration. Despite this, R87 stated that she never primed her insulin pens, believing it was unnecessary. The facility's policy on self-administration of medications required residents to correctly identify their medications and understand their use, but there was no specific policy on priming insulin pens. The director of nursing confirmed that residents should be priming their insulin pens to ensure proper dosage, highlighting a gap in the resident's education and the facility's oversight.
Failure to Provide Proper Nail Care for a Resident
Penalty
Summary
The facility failed to ensure proper nail care for a resident, identified as R95, who required assistance with personal hygiene due to moderately impaired cognition and lumbar stenosis. The resident's care plan specified that staff should trim his nails as needed during his weekly bath. However, progress notes from November 1 to November 19 lacked documentation that R95's fingernails had been cut or that he had refused to have them cut. Observations on November 18 and 19 revealed that R95's fingernails were approximately 1 inch long, and he expressed a desire to have them cut. Interviews with facility staff, including nursing assistants and a registered nurse, revealed inconsistencies in the responsibility for nail care. Nursing assistants were generally responsible for cutting nails unless the resident was diabetic, in which case nurses were responsible. The director of nursing confirmed this protocol and stated that nail care should be documented in progress notes, including any refusals. Despite these protocols, R95's nails were not trimmed as required, indicating a lapse in the facility's adherence to its policy on activities of daily living.
Failure to Attempt GDR and Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted for a resident using psychotropic medications. The resident, who had no cognitive impairment and did not exhibit symptoms of depression or anxiety, was prescribed Bupropion and Duloxetine for anxiety. Despite the consultant pharmacist's recommendations for a GDR, these were not received by the facility due to an IT glitch, and the GDR was not attempted. The facility's policy required a GDR within the first year of admission, but the process was not followed due to the communication failure between the consultant pharmacist and the facility. Another deficiency was identified when the facility failed to obtain informed consent for the use of Depakote, a psychotropic medication, for a resident with severe cognitive impairment and behavioral disturbances. The resident's care plan included the use of high-risk medications, and the medication administration record indicated the use of Depakote for restlessness and agitation. However, there was no evidence of a consent form for the use of Depakote, which is required to inform residents or their representatives of the risks, benefits, and potential side effects of the medication. Interviews with facility staff revealed a lack of awareness that Depakote was considered a psychotropic medication, and the director of nursing acknowledged the need for informed consent when medications are used outside their typical classification. The facility's policy required informed consent for psychotropic medications, but this was not adhered to in the case of the resident receiving Depakote.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure insulin was administered in accordance with professional standards of practice, resulting in a medication error rate of 9.09%. This deficiency was observed in two residents who were receiving insulin injections. The first resident, identified as R100, had a history of diabetes mellitus and required insulin injections daily. During an observation, an LPN administered insulin without priming the needle, which could potentially result in a subtherapeutic dosage. The resident's care plan and physician orders required regular blood glucose monitoring and specific insulin administration, which were not followed correctly. The second resident, R51, also had a history of diabetes mellitus with complications and required insulin injections. Similarly, an LPN administered insulin without priming the needle, contrary to the manufacturer's instructions. Interviews with staff revealed a lack of understanding regarding the necessity of priming insulin pen needles before administration. The facility did not have a specific insulin pen policy or procedure, relying instead on the manufacturer's instructions, which were not adhered to during the observed incidents.
Infection Control Deficiencies in Incontinence Care and Contact Precautions
Penalty
Summary
The facility failed to adhere to infection control standards during incontinence care for a resident identified as R40. The resident, who had intact cognition and was dependent on staff for toileting due to incontinence, was observed being cared for by a nursing assistant (NA-A) who did not follow proper hand hygiene protocols. NA-A used the same pair of gloves throughout the care process, which included cleaning a bowel movement, applying skin barrier cream, and handling the resident's call light cord. NA-A did not change gloves or perform hand hygiene between these tasks, despite acknowledging the need to do so during a follow-up interview. Additionally, the facility did not implement proper contact precautions for a resident identified as R364, who required such measures due to an ESBL-resistant urinary tract infection. Despite clear signage and available protective equipment outside the resident's room, a physical therapist assistant (PTA) entered the room and assisted the resident without donning a gown or gloves. The PTA acknowledged the oversight during an interview, confirming the expectation to wear protective gear under contact precautions. The facility's infection preventionist reiterated the importance of following hand hygiene and contact precaution protocols as per facility policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near White Bear Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waverly Gardens | 3.4 mi | ★★★★★ | 7 | 1 |
| Harmony Gardens | 4.3 mi | ★★★★★ | 7 | 0 |
| Maplewood Rehabilitation Center | 4.9 mi | ★★★★★ | 26 | 0 |
| Good Samaritan Society - Maplewood | 6.3 mi | ★★★★★ | 16 | 0 |
| Langton Shores | 6.9 mi | ★★★★★ | 1 | 0 |
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