All Saint's Subacute & Transitional Care
ALL SAINT'S SUBACUTE & TRANSITIONAL CARE in SAN LEANDRO, CA — inspection on August 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent observation and interview on 8/20/25 at 9:02 a.m. with CNA 5, Resident 6 laid in bed.
CNA 5 stated she was assigned to care for Resident 6 on 8/14/25 morning shift start time 7a.m. CNA 5 stated she checked on Resident 6 at around 8a.m. CNA 5 stated Resident 6 was clean and reposition. CNA 5 stated she does walk rounds with night shift CNA to check residents and make sure residents were cleaned and repositioned. CNA 5 stated she returned to Resident 6 around 10 a.m. for care because she has other residents to attend and was busy. CNA 5 said she did not see that Resident 6's draw sheet was stained with urine.
During an interview on 8/20/25 at 10:18 a.m. with Director of Staff Development (DSD), DSD stated he was informed that Resident 6's FM1 complained that Resident 6's draw sheet was saturated with urine stain and not changed overnight. DSD stated CNA 5 was interviewed and stated Resident 6's condom catheter was loose and may be leaking. DSD stated he was shown a picture of Resident 6 wet bed with saturated urine-stained draw sheet underneath Resident 6. DSD stated he followed up with night shift nurse CNA 4 and reminded CNA 4 and CNA 5 to check, clean and reposition Resident 6 every two hours and stress the importance of checking residents' incontinence episodes.
During an interview on 8/21/25 at 11:21 a.m. with Administrator (Admin), Admin stated facility was aware of a complaint on 8/14/25 that Resident 6 laid on a draw sheet that was saturated and stained with urine and had started investigation.
During a concurrent interview and record review on 8/22/25 at 10:15 a.m. with Director of Nursing (DON), Resident 6's bladder and bowel continence records, safety checks every 2 hours including positioning and assistance in bowel and bladder records were reviewed.
The safety checks every 2 hours records indicated on 8/14/25, Resident 6 was checked at 12:06 a.m. and next check was at 6:44 a.m. DON stated 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.
During a review of the facility's policy and procedure (P&P) titled, Repositioning, dated 2001, the P&P indicated, Residents who are in bed should be on at least an every-two-hour (q2hour) repositioning schedule.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting dated 2001, the P&P indicated, 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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.