All Saint's Subacute & Transitional Care

Inspectors wroteBased on observation, interview, and record review, the facility failed, for Residents 3, 4, 6 and 7, to ensure 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 interview and record review, the facility failed to ensure 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. Administrator 3 (ADM 3) was listed as the administrator from 3/14/2023 to 5/10/2024. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for two of five sampled residents (Resident 1 and Resident 2) for tracheostomy (a surgical procedure that creates an opening through the front of the neck directly into the trachea [windpipe]) care when:1. Resident 1 did not have a physician order for tracheostomy suctioning (a sterile procedure that uses a flexible catheter inserted through the tracheostomy to mechanically clear excess mucus or secretions from the trachea [a critical tube that connects voice box to lungs]) as indicated in Resident 1's care plan, and the facility did not have time-specific documentation demonstrating when the tracheostomy suctioning was provided to Resident 1. 2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the implementation of hydration monitoring for one of three sampled residents (Resident 1), when Resident 1's intake (I, fluid consumed) and (&) output (O, fluid excreted) monitoring during the PM shift (7:00 p.m. to 7:00 a.m.) was not maintained and the total 24-hour I&O (it is the clinical window used to evaluate fluid balance and it sums all fluid consumed against all fluid excreted over the preceding 24 hours to track trends and detect dehydration [loss of fluid] or fluid overload [too much fluid in the body]) was not calculated on 6/15/26, to evaluate Resident 1's overall fluid balance and hydration status. This deficient practice placed Resident 1 at risk for delayed identification of changes in fluid balance, including dehydration or fluid overload, and delayed implementation of appropriate interventions. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accurate and complete clinical documentation for one of three sampled residents (Resident 1), when the licensed nurse documented that medications were administered to Resident 1 on 6/16/26 at 5:00 a.m., the medications administration were not documented on Resident 1's Medication Administration Record (MAR- It is the official clinical record log that nurses and caregivers use to document what prescribed medication a patient receives, the dosage, the time it was administered, and the route). This deficient practice resulted in Resident 1's inaccurate and incomplete clinical record, which could affect Resident 1's ongoing clinical assessment, treatment decisions, and continuity of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff adhered to its infection control policies for one of three sampled residents (Resident 3) when housekeeper (HK 1) entered and cleaned Resident 3's room without wearing the required isolation gown (protective barrier to prevent the transfer of germs between patients and staff) while Resident 3 was on contact isolation precautions (safety measure to wear gloves and gown when in contact with an infected resident, surfaces or equipment) for MRSA (methicillin-resistant staphylococcus aureus, bacteria that does not respond to antibiotics) associated wounds to the left foot and left leg, increasing the risk of cross-contamination and transmission of healthcare-associated infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to meet professional standards of quality for one of three sampled Residents (Resident 1), when Resident 1 did not have their blood sugar level checked and/or received Insulin [medication for Diabetes Mellitus (DM - a chronic condition where the body cannot properly manage sugar in the blood leading to high levels that can damage organs)] as ordered by their physician. This failure had the potential for Resident 1 to experience life-threatening emergencies as well as severe organ damage. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for two of six sampled residents (Resident 1 and Resident 2 ) when the following was observed: 1. House Keeper (HK) 1 was seen inside Resident 1's room who was on Contact Precaution (extra safety steps healthcare workers take to stop spread of germs) without Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and did not perform hand hygiene after exiting Resident 1's room.2. Registered Nurse (RN) 1 did not wear PPE or wash their hands after giving a subcutaneous (medication delivered through injection under the skin) injection to Resident 1.3. [...]

Inspectors wroteBased on observation, interview, and record review, Facility 2 failed to follow infection control practices to prevent the spread of infection in Facility 2 when the following were identified: 1. Facility 2 did not follow the recommendations to stop the spread of infection as outlined by the local public health department (LPHD). The recommendations were as follows: a. Close Facility 2 to new admissions and halt movement of residents from other buildings to the facility . b. [...]

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 four of six sampled residents (Residents 11, 12, 15, and 31), when Residents 11, 12, 15, and 31 did not have a care plan to address their antibiotic-resistant infection called Carbapenemase-Producing Organisms (CPO, are bacteria that are resistant to a class of antibiotics called carbapenems which are typically used as a of last-line treatment for serious infections) specific to enzyme New Delhi [NAME]-ß-lactamase (NDM, an enzyme that makes bacteria resistant to a broad range of antibiotics including the carbapenem family). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of a controlled substance (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) when: 1. During a random controlled medication use audit, two of two randomly sampled residents (Resident 49 and Resident 15) did not have all administered medications correctly documented on the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medication) and on the Medication Administration Record (MAR) to indicate they were administered to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. Two containers of acetylcysteine (a medication used to break up mucus in people with lung disease) were not labeled with an open date. 2. An unopened insulin pen was stored in the medication cart. 3. Four bottles of eyedrops were not correctly labeled with a patient identifier. 4. Oral (taken by mouth) medications were stored in the same compartment in the medication cart as eye drops. These failures had the potential to result in eight residents potentially receiving an incorrect or expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were competent regarding job duties when: 1. A cook did not know the appropriate method for calibrating the thermometer. 2. A dietary aide did not demonstrate appropriate procedures for testing the sanitizer on the dish machine. 3. Kitchen staff did not know the appropriate sanitizer for sanitizing food contact surfaces. This failure had the potential to result in contamination of kitchen equipment and/or utensils leading to food borne illness caused by pathogens (harmful organisms) for 22 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when the following was noted: 1. Expired and beyond use by date of eight various dry seasonings were available for use. 2. A tabletop can opener was not clean. These failures placed 22 residents who received food from the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 40 and Resident 59) received assistance with Activities of Daily Living (ADL, those activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) to maintain good grooming and personal hygiene when Resident 40 and Resident 59 had long, thick facial hair. This failure resulted in Resident 40 and Resident 59 at risk for skin breakdown and irritation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 59), received proper tracheostomy (surgically created hole in the trachea or windpipe that provides an alternative airway for breathing) care when Resident 59's tracheostomy tie (a band that goes around the neck and hold the tracheostomy tube in place) was not changed daily as ordered by the physician. This failure resulted in Resident 59 being at risk for skin irritation and infection.

Inspectors wroteBased on interview and record review the facility failed to act upon consultant pharmacist's recommendations to add the correct indication of use for quetiapine (a medication used to treat certain mental/mood disorders) for one of five sampled residents (Resident 19). This deficient practice resulted in Resident 19 receiving unnecessary medication without proper indication and had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 13 residents who occupied 6 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Inspectors wroteBased on interview and record review, the facility failed to ensure the representative of one of three residents (Resident 1) received copies of medical records within 48 hours from requested date. This failure resulted in Resident 1's representative (RR) not receiving requested documents for 20 days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 14) received the physician-ordered treatment for his pressure ulcers. (A pressure ulcer refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device, commonly known as bed sores.) The failure to use the wound treatment ointment ordered by the physician, had the potential to result in delayed healing of Resident 14's pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Discharge Assessment Minimum Data Set (MDS, an assessment tool used to guide care) was completed within 14 calendar days for one of two sampled residents (Resident 53). This failure resulted in delayed completion and submission of Resident 53's Discharge Assessment MDS.

Inspectors wroteBased on observation and interview, the facility had six resident (Rt) rooms (Transitional care unit-TCU rooms 2, 3, 9, and North rooms 7, 12, 16) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for three of 15 sampled residents (residents 8, 28 and 41) when staff were standing over the residents while assisting them to eat. This deficient practice had the potential to cause residents to feel demeaned and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bedroom space equal to 80 square feet per resident (sf/resident) in: 1. Building A: three of 11 resident rooms (rooms [ROOM NUMBER]), affecting five of 20 facility residents, and 2. Building B: three of 21 resident rooms (rooms [ROOM NUMBER]), affecting six of 37 facility residents. These failures had the potential to result in inadequate space for delivery of care, or for resident belongings.