All Saints Healthcare Subacute

In the surveyor’s words

From the most serious findings on record at All Saints Healthcare Subacute, in the surveyor’s own words.

• Immediate jeopardy, patternF759Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%). Eleven (11) medication errors out of 26 total opportunities contributed to an overall medication error rate of 42.3% affecting 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3). The facility failed to: 1. Ensure LVN 1 did not mix three of eight medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one… […]

• Immediate jeopardy, patternF760Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3) on 10/18/2023, were free from significant medication errors (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). The facility failed to: 1. […]

• Immediate jeopardy, patternF684May 26, 2021

  Based on interview and record review, the facility failed to provide the necessary care and services in accordance with its policy and procedure, and professional standards of practice for one of six sampled residents (Resident 1) by: 1.) Failing to ensure that facility staff verified the pharmacy label against the dispensed bottle of [MEDICATION(S)] (medication to lower blood pressure) to ensure the correct dosage of medication was being administered to Resident 1. 2.) Failing to ensure staff reported a change of condition to the physician when Resident 1 experienced six episodes of low blood pressure resulting with the residents [MEDICATION(S)] (medication to lower blood pressure) being held as indicated in the plan of care. […]

• Immediate jeopardy, patternF760May 26, 2021

  Based on interview and record review, the facility failed to administer the correct dose of [MEDICATION(S)] (medication to lower blood pressure) to one of six sampled residents, (Resident 1). Resident 1 received twelve (12) doses of medication that was ten (10) times the intended prescribed dose between the days 3/22/2021 to 3/26/2021. This deficient practice severely compromised Resident 1's health and safety, increasing the potential for the need of hospitalization , and or resultant death of Resident 1. […]

• Immediate jeopardy, isolatedF689Nov 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), a two-year old, with severely impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), remained free from accident. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn her back on Resident 1, leaving Resident 1 unattended on a shower bed which had two gaps (open space) on each side of the side rails measuring eight inches (unit of measurement) in height and 22.5 inches in width, after CNA 1 transferred Resident 1 from his crib (a small bed for a baby or young child, with… […]