The incident occurred on August 14 when Resident 6's family member found the person lying on a draw sheet stained and saturated with urine. The family member took a photograph of the wet bed and filed a complaint with the facility.
Federal inspection records show the resident's safety check records indicated the last check occurred at 12:06 a.m., with the next documented check not until 6:44 a.m. The facility's own policy requires staff to check residents every two hours for positioning and incontinence care.
CNA 5, assigned to care for Resident 6 during the morning shift starting at 7 a.m., told inspectors she checked on the resident around 8 a.m. and found them "clean and repositioned." She said she conducted walk rounds with the night shift CNA to check residents and ensure they were cleaned and repositioned.
But CNA 5 admitted she didn't return to Resident 6 until around 10 a.m. "because she has other residents to attend and was busy." She told investigators she did not see that the resident's draw sheet was stained with urine.
The night shift worker, CNA 4, told inspectors he was assigned to check on Resident 6 every two hours. He said he did not observe the draw sheet with urine stains.
Director of Staff Development told investigators he was informed that the family member complained about the urine-saturated bedding that had not been changed overnight. During his follow-up investigation, CNA 5 explained that Resident 6's condom catheter was loose and may have been leaking.
The director said he was shown the family member's photograph of the wet bed with the saturated, urine-stained draw sheet underneath the resident. He followed up with both CNAs and reminded them to check, clean and reposition Resident 6 every two hours, stressing the importance of monitoring residents' incontinence episodes.
Administrator confirmed the facility was aware of the August 14 complaint and had started an investigation into the incident.
Director of Nursing reviewed Resident 6's bladder and bowel continence records with inspectors, along with the safety check documentation that should have occurred every two hours. The records clearly showed the gap between the midnight check and the morning check at 6:44 a.m.
"Her expectation was for nursing staff to follow the safety protocol, and check residents every 2 hours for positioning, incontinence care so residents are comfortable, clean and prevent wounds," according to the inspection report.
The facility's repositioning policy, dated 2001, specifically states that "Residents who are in bed should be on at least an every-two-hour repositioning schedule."
Another policy covering activities of daily living indicates that "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."
The violation represents what inspectors classified as minimal harm or potential for actual harm, affecting some residents at the 150-bed facility.
The inspection occurred following the family's complaint, with investigators conducting interviews and observations over three days in August. The facility has been operating under the same basic care policies since 2001, according to the documentation reviewed during the investigation.
State inspectors found that despite clear policies requiring two-hour safety checks, staff failed to follow the protocol, leaving a resident lying in urine-soaked bedding for an extended period. The incident highlights ongoing challenges with staffing levels and adherence to basic care standards at the San Leandro facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for All Saint's Subacute & Transitional Care from 2025-08-22 including all violations, facility responses, and corrective action plans.
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