All Saint's Maubert

Inspectors wroteBased on interview and record review, the facility failed to have a Director of Nursing for more than 5 months. This failure placed all residents at risk of substandard nursing care due to absence of leadership, oversight and accountability. During an interview on 8/18/25, at 10:08 a.m., with a different Facilty's Director of Nursing (FDON), FDON stated they were not the designated director of nursing and had assisted in collaboration with the Assistant Director of Nursing (ADON) with duties which needed a registered nurse. During a concurrent interview and record review on 8/19/25, at 10:01 a.m., with Human Resources, FDON's acceptance letter to another facility, untitled, dated 4/4/25, was reviewed. HR stated the letter indicated FDON was hired as the Director of Nursing at another facility. HR stated FDON was hired full time at another facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for Residents 1, 5, 6, 7, 8 and 9, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion. In addition, these failures resulted in the potential for avoidable medication errors.

Inspectors wroteBased on interviews and a review of facility records, the facility failed to ensure that a state licensed Nursing Home Administrator was overseeing facility operations when the unlicensed Operations Manager (OM) had assumed the role of administrator for more than 11 months. This failure resulted in residents, staff and facility operations being supervised and directed by unqualified administrative leadership for more than 11 months. During a record review of state nursing home administrator licensing database titled, Licensing and Certification License Verification Page, the database indicated OM did not have a Nursing Home Administrator license. During a review of state nursing home database titled, ELMS, the database indicated ADM 2 was the reported Administrator of the facility from 11/4/2020 to 3/13/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a director of nursing for more than 5 months. This failure placed all residents at risk of substandard nursing care due to absence of leadership, oversight and accountability. During an interview on 8/18/25, at 10:08 a.m., with a different Facility's Director of Nursing (FDON), FDON stated they were not the facility's designated director of nursing and had assisted in collaboration with the Assistant Director of Nursing (ADON) with duties which needed a registered nurse. During a concurrent interview and record review on 8/19/25, at 10:01 a.m., with Human Resources, FDON's acceptance letter to another facility, untitled, dated 4/4/25, was reviewed. HR stated the letter indicated FDON was hired as the director of nursing at another facility. HR stated FDON was hired full time at another facility. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when food items were stored less than six inches above the floor. These failures had the potential for contamination of food resulting in food borne illness for the 10 residents who lived at the facility. During an observation 8/18/25, at 3:09 p.m., central supply was observed with tube feeding formulas stored less than six inches above the floor. During an interview on 8/21/25, at 10:39 a.m., with Registered Dietician (RD), RD stated food stored less than six inches above the floor was a risk for contamination from pests, could have altered the food temperature and had the potential to cause resident sickness. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for three sampled residents (Resident 2, Resident 15, Resident 16) when:Resident 2, 15, and 16's care plans did not address the use of psychotropic medications such as lorazepam (antianxiety) and sertraline (antidepressant), Modafinil (stimulant) for behavioral manifestations. Psychotropic medications are drugs used to treat mental illness. These deficient practices had the potential to result in the residents not receiving appropriate care, monitoring, and treatment. During a review of Resident 2's order summary dated 8/3/25, the order summary indicated the physician prescribed bupropion 100 mg Give 1 tablet via NG-Tube one time a day for depression manifested by (m/b) feeling sad; buspirone 10 mg Give 1 tablet via NG-Tube two times a day for anxiety m/b inability to relax; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident 2, Resident 15, Resident 16) of three sampled residents were free of unnecessary drugs, when they were receiving psychotropic medications without being monitored for their target behaviors. These failures had the potential for residents to receive unnecessary medications and suffer adverse medication side effects. Definitions:Lorazepam - an anti-anxiety medication to reduce tension or anxiety. Its adverse consequences include increased risk of confusion sedation, and fallsBupropion is an antidepressant medication for depression. Its adverse consequences include agitation or anxiety, trouble sleeping, and suicidal thoughtsBuspirone - an anti-anxiety medication for short-term relief of anxiety symptoms. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate of less than five percent when four errors were observed in 33 medication pass opportunities for four out of five sampled residents (Resident 9, Resident 10, Resident 17) resulting in 12.12% medication error rate. The errors were: Three residents were not identified using the required minimum of two resident identifiers prior to administering medications to each of them. For Resident 9, no physician or pharmacy clarification was done for a medication, fludrocortisone acetate tablet (a medication that increases blood volume and blood pressure) that had a Hold parameter on the bubble pack and had no parameters on the physician order for Resident 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor and document the necessity of a physical restraint for one out of one resident (Resident 16), when staff did not monitor and document their specific reason for the restraint as ordered by their doctor for four days. This failure had the potential to result in isolation, depression and the unnecessary restraint of Residents 16. During a review of Resident 16's admission Record, printed 8/20/25, the record indicated Resident 16 was admitted to the facility in August 2025 with a diagnosis of Tracheostomy Status (an incision in the windpipe made to relieve an obstruction to breathing). During an observation on 8/18/25, at12:35 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - mental health assessment tool) for one of one sampled resident (Resident 8) was completed and coded accurately. This failure placed Resident 8 at risk to not receiving care and services appropriate to his needs. During a review of Resident 8's admission Record undated, the admission record indicated Resident 8 was admitted on [DATE] and has diagnosis of paranoid schizophrenia, a severe mental disorder characterized by hallucinations (sensory experiences like hearing voices) and delusions (fixed false beliefs), particularly involve persecution or being threatened. During a concurrent interview and record review on 8/22/25 at 9:10 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) received good grooming when Resident 6 had long thick nails and facial hair. The failure placed Resident 6 at risk for having skin irritations and infections, and compromising his physical health, and not preserving his dignity. During a review of Resident 6's undated admission record, the admission record indicated Resident 6 was readmitted on [DATE] and originally admitted on [DATE] with multiple diagnoses that included anoxic brain damage (condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), dependent on a respirator and tracheostomy (a surgically created hole in the windpipe that provides alternative airway for breathing. [...]

Inspectors wroteBased on observation, interview, and record review, Facility 1 failed to follow infection control practices to prevent the spread of infection in the facility when the following were identified: 1. Facility 1 did not demonstrate infection prevention practices were implemented as evidenced by the line list (a table that contains key information about each case in an outbreak) that showed uninfected residents becoming infected. 2. Facility 1 did not notify California Department of Public Health (CDPH) about the infection outbreak. 3. [...]

Inspectors wroteBased on interview and record review, Facility 1 failed to ensure that a designated Infection Preventionist (IP) that adequately assesses, develops, implements, monitors, and manages the facility's Infection Prevention Control Program (IPCP) was employed at the facility . This failure resulted in an increase of Carbapanemase-Resistant Organism (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used a last-line treatments for serious infections) infections in the Facility 1. Furthermore, the cross-contamination resulted in transmission of the infections to non-infected residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan (a document that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), for two of five sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 did not have a care plan to address their antibiotic-resistant infection, Klebsiella Pneumoniae Carbapenemase (KPC, a group of emerging highly drug-resistant Gram-negative bacilli bacteria causing infections associated with significant morbidity and mortality). This failure had the potential for Resident 1 and Resident 2 to not receive person-centered appropriate care, monitoring, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications when medications were stored in the Director of Nursing (DON) office that had the door completely open and without supervision. This failure had the potential to result in loss or diversion of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement infection control and prevention policies and procedures as evidenced by the following: 1. The facility laundry room contained: Clean mop heads, unused cleaning cloths, and unused Restorative Nurses Aids (RNA) Slings (a vest used by staff when assisting residents with mobility), stored in the same area as items waiting to be laundered. Staff personal use items: sweater, shawl, and a cup of coffee were in the area designated for clean resident linens. 2. Laundry Aide (LA) mopped the clean and dirty laundry room areas with the same mop head, using a solution with unknown chemicals. 3. The Soiled Utility Room had liquid medical waste (used suction canisters) containers stored together with biohazardous sharps (used needles, scalpels, scissors, etc.) containers. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to take reasonable care for the protection of one (Resident 6) of eleven sampled residents' clothing from loss or theft. The facility failure to ensure residents clothing was labeled before laundering resulted in an inability to identify specific ownership of clothing and subsequent loss of clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care consistent with professional standards of practice for one (Resident 66) of eleven sampled residents when: the nursing staff inaccurately documented wound status, nursing staff failed to perform hand hygiene before donning gloves before wound treatment, and a certified nursing assistant incorrectly cleaned a wound. These failures placed residents at risk for infection, for wounds to worsen, and new wounds to develop. See also tags F 656, F697, and F 726.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff had sufficient skills and competencies to perform wound care treatments for one (Resident 66) of 11 sampled residents. The failure to ensure Registered Nurse 1 (RN 1) was able to accurately assess and document Resident 66's pressure wounds had the potential to result in development or worsening of Resident 66's pressure ulcers. (A pressure ulcer develops when one or more layers of skin and tissue are damaged from continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone.) See also tags F 656, F 686, and F 697.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement policies and procedure (P&P) designed to prevent contamination of food during preparation and storage when: 1. Two kitchen staff did not wear hair nets in the kitchen. 2. The facility's dry storage room contained cans of food with no use-by date. 3. The facility's refrigerator had bloody red meat dated 10/18/23, with no indication of what the date meant. These failures placed residents of the facility at risk to consume outdated food and to develop food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, functional, and sanitary environment when there were broken lights in the hallway. This failure placed residents at risk of receiving the wrong medication due to inadequate light for reading the medication labels and placed residents and visitors at risk of falling.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the rights of two of 11 (Resident 6 and 66) sampled residents when the facility displayed signage above their beds with their personal information visible to those who had no permission or right to see it. This failure resulted in Resident 66 feeling exposed and the Responsible Party (RP 6) for Resident 6 to voice feelings of disrespect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/update and implement a comprehensive person-centered care plan for one (Residents 66) of 11 sampled residents when Resident 66 complained of ongoing pain and emotional distress during wound treatments. The facility failure to update and implement Resident 66's care plan to address his pain and anxiety during wound treatments, resulted in Resident 66 experiencing ongoing pain and anxiety. See also tags F 686, F 697, and F 726.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure injury (injury due to prolonged pressure over an area) reducing devices were applied for one of 11 (Resident 4) sampled residents. This failure had the potential for Resident 4's existing left heel wound to worsen and for the right heel to develop a new wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to one (Resident 66) of eleven sampled residents. The facility failed to provide pain medication for Resident 66 prior to a painful procedure and failed to provide pain medication as requested for pain. This failure resulted in Resident 66 having recurrent pain and anxiety during daily wound treatments. See also tags F 656, F 686, F 726.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of 11 (Resident 8 and 65) sampled residents when: 1. Resident 8 was administered multi-vitamin with minerals tablet instead of multi-vitamin with minerals liquid 15 mL (mL, a unit of liquid measurement) as prescribed by physician's order; 2. Resident 65 did not receive erythromycin ophthalmic ointment 5mg/gm (mg/gm, a measurement of medication concentration) as prescribed by physician's order. This failure resulted in 2 medication errors out of 33 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 6.06%. This failure also resulted in residents not receiving the correct medication or receiving the medication as prescribed.

Inspectors wroteBased on interview and record review, the facility failed to implement their vaccine Policy and Procedure (P&P) for one (Resident 66) of eleven sampled residents. The facility failure to offer a Covid vaccination to Resident 66 had the potential to result in Covid-19 infection, worsened symptoms in the event of infection, and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 residents (Resident 5, Resident 113) received services according to national standards to prevent and/or promote healing of pressure ulcers (tissue damage because of pressure injury) when: 1. Nursing staff failed to use standardized techniques to assess, measure, and document Resident 5's pressure ulcers. (A pressure ulcer develops when one or more layers of skin and tissue are damaged because of continuous pressure to the area. The depth of skin and tissue damage determines the stage of the pressure ulcer, which is on a scale of stage I to stage IV, with stage I the most superficial, and stage IV the deepest ulcer, including damaged skin and muscle down to the level of bone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post nurse staffing data to include the total actual hours worked by registered nurses, licensed vocational nurses, and certified nurse assistants directly responsible for resident care. This failure resulted in unavailability of nurse staffing information for residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two nursing staff followed hand hygiene procedures when Registered Nurse 1 (RN 1) and Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene between glove changes during wound care for one of thirteen sampled residents (Resident 12). This failure had the potential to result in infection or the spread of infectious organisms.