All Saint's Maubert

In the surveyor’s words

From the most serious findings on record at All Saint's Maubert, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Mar 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Jul 3, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF755Jul 3, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF839Jul 3, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF727Aug 22, 2025

  Based 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. […]