All Saints Healthcare Subacute's Director of Nursing admitted the facility's policies weren't followed after Resident 1's fall incident. The admission came during interviews with inspectors on November 5, when the DON acknowledged that a mandatory facility-wide assessment should have been completed but wasn't.
The facility's own policy, reviewed in March 2025, requires a designated team to conduct comprehensive assessments "once a year, and as needed" to ensure resources meet residents' specific needs. The assessment must include a detailed review of equipment and supplies, both medical and non-medical.
But the DON told inspectors the facility assessment was incomplete. More critically, she said the assessment failed to account for pediatric-sized shower beds, despite the facility currently housing 33 children.
The Pediatric Nurse Manager revealed during a November 6 interview that the pediatric subacute unit serves residents ranging from one year old to an unspecified older age. She said Resident 1 had been admitted on a date redacted from the inspection report.
"Since the facility admitted Resident 1, the facility should have made sure that all equipment needed by Resident 1 will be size-appropriate for safety and that includes pediatric shower bed," the PNM told inspectors.
She added that the 2025 Facility Assessment should have included shower bed specifications.
The Administrator echoed these concerns during a November 8 interview, stating the facility assessment should be updated with current equipment used by the facility, including shower beds.
Inspectors discovered the shower bed used by a certified nursing assistant for Resident 1 came with explicit safety warnings that appeared to have been ignored. The Healthcare Equipment Owner's Manual, revised in January 2008, contained multiple critical warnings about proper use.
The manual warned that individuals should never be left unattended in shower chairs, walkers, geri-chairs, low beds, recreational chairs, shower gurneys, cribs, or therapy cars. It emphasized that caregivers should be present and alert at all times while equipment is in use.
Most significantly, the manual stated that equipment may not be appropriate for all individuals and that assessment should be conducted by a skilled caregiver to determine proper suitability for each person using the equipment.
The manual also warned about improper use of the equipment, though the inspection report cuts off mid-sentence at this point.
The facility's failure to conduct the required assessment after Resident 1's fall represents a breakdown in basic safety protocols. Federal nursing home regulations require facilities to maintain comprehensive assessments of their resources and resident population needs, particularly when incidents occur that might indicate gaps in care or equipment.
The immediate jeopardy citation indicates inspectors found conditions that posed immediate threat to resident health and safety. This is the most serious level of violation federal inspectors can issue, typically reserved for situations where residents face imminent risk of serious injury, harm, or death.
The timing of the violation is particularly concerning. Resident 1's fall occurred on October 24, but the facility assessment that should have followed remained incomplete when inspectors arrived two weeks later for their November 5-8 survey.
For a facility serving children as young as one year old, the lack of appropriate pediatric equipment poses heightened safety risks. Young residents require specialized equipment designed for their size, weight, and developmental needs.
The inspection report doesn't detail the circumstances of Resident 1's fall or specify whether inadequate equipment contributed to the incident. However, the facility's own nursing leadership acknowledged that proper pediatric shower beds should have been part of their safety assessment.
The DON's admission that policies weren't followed suggests systemic problems beyond the single incident. When nursing home staff fail to implement required safety protocols after resident injuries, it indicates potential gaps in training, oversight, or commitment to resident protection.
All Saints Healthcare Subacute operates at 11810 Saticoy Street in North Hollywood, serving what appears to be a unique population of pediatric residents requiring subacute medical care. The facility's specialized role in caring for children makes equipment appropriateness and safety assessments even more critical than in typical nursing homes.
The inspection was conducted in response to a complaint, suggesting someone outside the facility raised concerns about care quality or safety practices. Federal inspectors completed their survey on November 8, finding violations serious enough to warrant immediate jeopardy status.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for All Saints Healthcare Subacute from 2025-11-08 including all violations, facility responses, and corrective action plans.
Additional Resources
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