Resident 85 arrived at the facility on December 16, 2025, with multiple serious conditions. The resident breathed through a surgically created opening in their neck and received nutrition through a feeding tube directly to their stomach. They lacked the mental capacity to make decisions and depended on staff for all daily care activities.
The facility's own immunization records contained no documentation that staff ever offered the COVID vaccine to Resident 85. No records showed the resident had declined vaccination either.
Licensed Vocational Nurse 6, who assists with vaccine data entry, confirmed the absence of any COVID vaccination documentation during a January interview with state inspectors. "There was no documentation in Resident 85's clinical record that Resident 85 was offered, declined, or was administered the Covid vaccine upon admission," she told investigators.
The facility maintains a tracking system for flu, pneumonia, and COVID consent forms for the 2025-2026 season. Resident 85's name did not appear anywhere on that tracker.
This oversight directly contradicted the facility's written vaccination policy, last reviewed in January 2025. The policy explicitly states that "all new residents shall be assessed for current vaccination status upon admission." It requires documented consent or declination from residents or their responsible parties before vaccine administration, and mandates that any refusals be recorded in medical records.
The Director of Nurses acknowledged the policy violation during her interview with inspectors on January 29. She stated that failing to offer vaccines to residents upon admission "was not aligned with the facility's policy."
More concerning, she explained the medical risks this created. Not offering vaccines "put immunocompromised residents at risks for infections," she told inspectors. The director emphasized that "each resident should be screened by the Infection Preventionist upon admission."
Resident 85's medical profile made them particularly vulnerable to COVID complications. Their chronic respiratory failure meant their lungs could not properly move oxygen into the blood or remove carbon dioxide. The tracheostomy and ventilator dependency indicated severe breathing difficulties.
Federal regulations require nursing homes to educate residents and staff about COVID vaccination and offer the vaccine to eligible individuals after providing education. Facilities must properly document each person's vaccination status.
The inspection found this failure affected few residents, but the potential consequences were significant. COVID-19 remains a highly contagious respiratory illness that can cause severe complications, particularly for individuals with compromised immune systems and existing respiratory conditions.
State inspectors classified this as a violation with minimal harm or potential for actual harm. However, the failure to follow basic vaccination protocols for a medically fragile resident highlighted gaps in the facility's infection control procedures.
The facility's vaccination policy includes specific requirements for documentation. When vaccines are refused, the policy mandates that "the refusal shall be documented in the resident's medical record." In Resident 85's case, no such documentation existed because staff never initiated the vaccination discussion.
This represents a fundamental breakdown in admission procedures. The facility had clear written protocols requiring vaccination assessment for every new resident. Staff responsible for vaccine tracking confirmed these protocols were not followed. The Director of Nurses acknowledged both the policy violation and the medical risks it created for vulnerable residents.
The inspection occurred nearly six weeks after Resident 85's admission, providing ample time for staff to complete the required vaccination screening. The resident's December 28 assessment confirmed their continued presence at the facility and ongoing need for comprehensive care.
All Saints Healthcare's failure to offer COVID vaccination to this ventilator-dependent resident violated both federal requirements and the facility's own policies, potentially exposing a medically fragile individual to preventable health risks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for All Saints Healthcare Subacute from 2026-01-29 including all violations, facility responses, and corrective action plans.