All Saint's Subacute & Transitional Care

In the surveyor’s words

From the most serious findings on record at All Saint's Subacute & Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Aug 22, 2025

  Based on observation, interview and record review, the facility failed to ensure all 59 residents who lived in the subacute building were free from environmental hazards when:1. A free-standing propane (flammable gas used for cooking or heating) tank and a propane tank attached to a gas grill were stored indoors in the subacute building in a hallway next to the kitchen and where a year's supply of emergency supplies were stored.2. Four ceiling mounted televisions (TV) were found partially detached from the ceiling and dangling over four of the 59 current residents (Resident 3, 7, 33 and 69) who were unable to move or protect themselves.These failures placed:1. […]

• Immediate jeopardy, widespreadF880Mar 25, 2025

  Based 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. […]

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

  Based 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. […]

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

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Aug 22, 2025

  Based on interview, and record review, the facility failed to ensure sufficient staffing when the weekend staffing levels were excessively low across four fiscal year (FY) quarters, and the minimum requirement of 2.4 Direct Hours Per Patient Day (DHPPD - refers to the minimum number of direct care service hours a facility is required to provide to each resident per day) of direct nurse aide coverage was not met on 15 audited days. This failure had the potential to result insufficient nursing staff and inadequate nursing care for the facility residents. […]