Resident 85 entered the facility on December 16, 2025, breathing through a surgically created opening in their neck and requiring a machine to support their lungs. The resident also relied on a feeding tube inserted directly into their stomach and needed complete assistance with basic activities like bathing and dressing.
The resident's medical assessment confirmed they lacked the capacity to understand and make decisions about their care.
Despite these severe vulnerabilities to respiratory illness, no one at All Saints Healthcare screened Resident 85 for COVID vaccination upon admission. The facility's immunization record contained no documentation showing the vaccine was offered, administered, or declined.
The resident's name never appeared on the facility's flu, pneumonia, and COVID consent tracker for the 2025-2026 season.
Licensed Vocational Nurse 6, who assists with vaccine data entry, confirmed during a January 29 interview that Resident 85's clinical record contained no evidence the COVID vaccine was ever discussed. "There was no documentation in Resident 85's clinical record that Resident 85 was offered, declined, or was administered the Covid vaccine upon admission," the nurse told inspectors.
The Director of Nurses acknowledged the failure violated facility policy during her interview the same day. She stated that not offering vaccines to residents upon admission "was not aligned with the facility's policy" and put immunocompromised residents at risk for infections.
Each resident should be screened by the infection preventionist upon admission, the director said.
The facility's own vaccination policy, last reviewed in January 2025, requires assessment of all new residents' vaccination status upon admission. The policy mandates obtaining consent or declination from the resident or their responsible party before administering vaccines.
If vaccines are refused, the policy states the refusal must be documented in the resident's medical record.
None of this happened for Resident 85.
The oversight represents a particularly serious gap given the resident's medical profile. Chronic respiratory failure means the lungs cannot properly move oxygen into the blood or remove carbon dioxide. Combined with ventilator dependence and a tracheostomy, Resident 85 faced extreme vulnerability to COVID-19, a respiratory illness that has proven especially dangerous for people with compromised lung function.
The resident's feeding tube indicated additional swallowing problems, another risk factor for respiratory complications.
Federal inspectors classified the violation as having caused minimal harm or potential for actual harm to few residents. However, the failure to follow basic vaccination screening protocols occurred during a period when COVID-19 continued circulating in healthcare settings nationwide.
The inspection took place nearly five years into the pandemic, well after vaccination protocols had become standard practice in nursing homes. Federal health officials had repeatedly emphasized the critical importance of COVID vaccination for nursing home residents, who experienced some of the highest death rates during the pandemic's early phases.
All Saints Healthcare's vaccination tracking system appeared functional for other residents, making the oversight for Resident 85 more notable. The facility maintained a consent tracker for flu, pneumonia, and COVID vaccines for the current season, but somehow failed to include this high-risk resident in the process.
The Director of Nurses' acknowledgment that the lapse put immunocompromised residents at risk underscored the potential consequences. Nursing homes serve as congregate living settings where respiratory illnesses can spread rapidly among vulnerable populations.
For Resident 85, the missed opportunity meant remaining unprotected against a virus that specifically targets the respiratory system they already struggled to support. The resident's inability to understand and make decisions about their care made staff screening and advocacy even more crucial.
The inspection report did not indicate whether the facility subsequently offered Resident 85 the COVID vaccine or updated their vaccination status following the inspectors' discovery.
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.