Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at All Saint's Subacute & Transitional Care during CMS and state inspections, most recent first.
A resident with Type 2 DM and a G-tube, who was cognitively intact and care planned for imbalanced nutrition and risk of unstable blood glucose, did not receive ordered blood glucose monitoring and Humalog insulin per sliding scale at a scheduled time. The resident and responsible party reported missed blood sugar checks and insulin doses on multiple occasions, including one specific evening. Review of the MAR confirmed that the blood sugar was not checked and insulin was not administered at the ordered time, and no justification was documented by the nurse, contrary to facility policies requiring adherence to provider orders and timely medication administration.
Staff failed to follow PPE and hand hygiene requirements for two residents on contact precautions. One resident with diabetes and a G-tube had a housekeeper enter the room, clean the bathroom, and handle trash without PPE or hand hygiene, despite posted contact precaution signage and facility policy. An RN also entered this resident’s room without PPE, administered G-tube medication, checked blood sugar, and gave insulin, then left the room without performing hand hygiene, later acknowledging that PPE and hand hygiene were required but citing an empty PPE rack at the door. Another resident with a tracheostomy, G-tube, and ventilator-associated pneumonia had a CNA empty a urinary drainage bag while wearing a gown and gloves, then exit the room, remove the gown in the hallway, keep the soiled gloves on while walking to the nurse’s station, and touch clean gowns without performing hand hygiene, again in conflict with the posted "5 Moments for Hand Hygiene" and the facility’s hand hygiene policy.
Three residents did not receive necessary care as required by their care plans and facility policy. Two residents, both fully dependent on staff for oral hygiene due to complex medical conditions, were observed with significant oral debris and dryness, indicating oral care was not performed as required each shift. Another resident, who was comatose and dependent for toileting, was found by a family member lying on a urine-saturated draw sheet, with facility records showing a lapse in required two-hour safety checks and repositioning. Staff interviews confirmed inconsistencies in care delivery.
A facility failed to follow infection control recommendations from public health authorities, including halting new admissions and resident transfers, submitting required monitoring logs, and ensuring staff adherence to hand hygiene and PPE protocols. Direct care staff were observed entering rooms of residents on contact precautions without proper hand hygiene or PPE, and staff caring for infected and non-infected residents were not separated. These failures led to the spread of multi-drug resistant organisms and carbapenem-resistant organisms among numerous residents, many with complex medical conditions.
Four residents with complex medical conditions and confirmed NDM infection did not have individualized care plans addressing their antibiotic-resistant infection. The facility focused on isolation procedures rather than creating person-centered care plans specific to each resident's infection, contrary to facility policy and best practices.
The facility failed to accurately document controlled substances for two residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). For one resident, alprazolam was not recorded on the MAR, and for another, morphine orders were inconsistently documented. Additionally, the medication cart was found unlocked twice, contrary to facility policy requiring it to be locked when out of view.
The facility failed to properly store and label medications, including acetylcysteine without open dates, an insulin pen stored outside the refrigerator, and oral medications mixed with eye drops. Additionally, eye drops were labeled only with room numbers, risking administration errors.
The facility's kitchen staff demonstrated incompetence in essential procedures, including incorrect thermometer calibration, improper sanitizer testing, and misuse of sanitizing solutions, risking contamination for 22 residents.
The facility failed to follow food safety standards by using expired seasonings and maintaining unclean kitchen equipment. Eight seasonings were found expired or beyond use-by dates, and a tabletop can opener had residue build-up. The Registered Dietician confirmed these issues, which put 22 residents at risk for foodborne illnesses.
Two residents in an LTC facility, both with significant medical conditions and total dependence on staff for personal hygiene, were observed with long, thick facial hair, indicating a failure to provide necessary grooming assistance. A CNA was unsure of her responsibilities, and the DON acknowledged the risk of skin irritation and compromised dignity. Facility policy requires assistance for residents unable to perform ADLs.
A resident with a tracheostomy and ventilator dependence did not receive proper care as their tracheostomy tie was not changed daily as ordered by the physician. The tie, last changed nearly a month prior, posed risks of skin irritation and infection. Discrepancies were noted between the facility's practice and the physician's order, with staff acknowledging the oversight.
A facility failed to implement a consultant pharmacist's recommendations for a resident's medication regimen. The resident continued to receive quetiapine without the correct indication documented, despite recommendations to update the diagnosis to 'dementia with behaviors - biting'. The facility's policy requires action on such recommendations within 30 days, which was not followed.
The facility did not meet the required 80 square feet of space per resident for 13 residents in 6 multi-bed rooms, with space per bed ranging from 72.87 to 79.75 square feet. Despite this, care provision was not hindered, and residents had adequate personal space and privacy, with no complaints or negative consequences reported.
Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a resident with Type 2 Diabetes Mellitus and a G-tube did not have blood glucose monitoring and insulin administration performed as ordered. The resident’s admission record showed diagnoses including Type 2 Diabetes Mellitus with hyperglycemia and gastrostomy status, and the MDS assessment documented intact cognition with a BIMS score of 15 and a diagnosis of Diabetes Mellitus. The resident’s care plan, initiated in April 2023, identified imbalanced nutrition related to insulin resistance and risk for complications such as unstable blood glucose and cardiovascular disease, with an intervention specifying diabetes medication as ordered by the physician. During an interview with the resident and the resident’s responsible party, both reported that the resident’s blood sugar was not checked and insulin was not administered on multiple occasions, including a specific evening. Review of the MAR for that date and time confirmed that the resident’s blood sugar was not checked and Humalog insulin, ordered every six hours per sliding scale, was not given at the scheduled 6:00 p.m. dose, and the licensed nurse did not document any justification for the missed insulin administration. The facility’s policies on diabetes care and medication administration required following provider orders for blood glucose monitoring, assisting with the prescribed medication regimen, and administering medications safely, timely, and in accordance with prescriber orders within one hour of the prescribed time, which was not followed in this instance.
Failure to Follow PPE and Hand Hygiene Requirements for Residents on Contact Precautions
Penalty
Summary
The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies, including contact precautions and hand hygiene, for two residents on contact precautions. Resident 1’s admission record showed admission with diagnoses including Type 2 diabetes mellitus with hyperglycemia and gastrostomy status, and a physician’s order placed the resident on contact precautions. Facility signage outside the room directed everyone to clean their hands before entering and when leaving, and directed staff to don gloves and gowns before room entry and discard them before room exit. Despite this, a housekeeper entered Resident 1’s room without any PPE, cleaned and emptied the bathroom and trash bins, then exited the room and did not perform hand hygiene. The housekeeper stated she knew PPE was required when cleaning Resident 1’s room but reported there was no PPE supply available that morning on the rack. Further noncompliance with infection control measures occurred when an RN provided direct care to Resident 1 without PPE and without performing hand hygiene. Resident 1’s physician orders confirmed contact precautions, and the facility’s hand hygiene policy required hand hygiene after contact with blood, body fluids, contaminated surfaces, after touching a resident, after touching the resident’s environment, and immediately after glove removal. During observation and interview, the RN was seen in Resident 1’s room without PPE, then exited without hand hygiene. The RN acknowledged that PPE was supposed to be worn because the resident was on contact precautions and explained that the PPE rack on the door was empty and PPE was stored at the nurse’s station. The RN confirmed having direct contact with Resident 1 by administering medication via G-tube, checking blood sugar, and giving insulin, and acknowledged not performing hand hygiene after this direct care and that this created an increased risk of transmission of infection. Resident 2’s records showed admission with tracheostomy status, gastrostomy status, and ventilator-associated pneumonia, and a physician’s order and care plan placed the resident on contact precautions. The care plan required staff to perform handwashing after completing care and leaving the room and to use PPE. During observation, a CNA was seen at Resident 2’s bedside emptying a urinary drainage bag while wearing a gown and gloves. The CNA then exited the room, removed and discarded the gown in a trash bin located in the hallway outside the room, but did not remove the soiled gloves. The CNA walked toward the nurse’s station while removing the gloves and touched a clean pack of gowns at the station. The CNA stated he removed the gown in the hallway because the garbage bin was outside the room and admitted he did not perform hand hygiene after emptying the urinary bag because he did not think about it. The CNA also reported that the PPE rack on Resident 2’s door was empty and that he had to obtain PPE from the nurse’s station. The facility’s hand hygiene policy and posted "Your 5 Moments for Hand Hygiene" signage required hand hygiene immediately after exposure risk to body fluids, after touching a patient or their surroundings, and immediately after glove removal, which was not followed in this instance.
Failure to Provide Timely Oral and Incontinent Care
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment, and care plan for three residents. Two residents, both dependent on staff for oral hygiene due to conditions such as traumatic brain injury, ventilator dependence, and gastrostomy status, did not receive proper oral care. Observations revealed one resident with dried, tan-colored matter on the lips and brown, dry matter at the corners of the mouth, as well as sticky, creamy matter inside the mouth. The other resident was observed with a dry, coated upper lip and a thick, peeling layer of skin. Staff interviews confirmed that oral care was not performed as required every shift, and facility policy stated that oral care should be provided every shift and as needed for residents with special needs. Another resident, who was comatose, dependent for toileting hygiene, and used an external urinary condom catheter, did not receive timely incontinent care. A family member reported finding the resident lying on a draw sheet saturated with dry urine up to the shoulders and upper body, and that nursing staff had not repositioned or changed the soiled linen. Facility records indicated a gap in required two-hour safety checks, with the resident not being checked for over six hours during the night. Staff interviews provided conflicting accounts regarding the resident's condition and care provided during the relevant period. Facility policies required residents who are unable to carry out activities of daily living independently to receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, as well as to be repositioned at least every two hours. The failure to adhere to these policies resulted in residents not receiving the necessary oral and incontinent care as outlined in their care plans and facility procedures.
Failure to Follow Infection Control Practices Resulting in Widespread MDRO and CRO Transmission
Penalty
Summary
Facility 2 failed to implement and follow infection prevention and control practices as recommended by the local public health department (LPHD), resulting in the spread of multi-drug resistant organisms (MDROs) and carbapenem-resistant organisms (CROs) among residents. Despite explicit recommendations from the LPHD to halt new admissions and prevent movement of residents between buildings, the facility continued to admit and transfer residents from another facility under a different license. The facility also did not submit required adherence monitoring logs for hand hygiene, PPE use, and environmental cleaning, nor did it provide complete line lists with laboratory test dates for residents who tested positive for CROs. Additionally, the facility failed to notify the California Department of Public Health about the outbreak in a timely manner and did not provide adequate documentation of outbreak notification and education to residents and families. Direct care staff were observed not following basic infection control protocols, such as performing hand hygiene and donning appropriate PPE before entering rooms of residents on contact precautions. For example, a CNA entered a resident's room without hand hygiene or PPE, embraced the resident, and then exited the building, despite a contact precaution sign being posted. These lapses in infection control were observed during surveyor visits and interviews, and staff confirmed that recommended practices were not consistently followed. The facility also failed to separate staff caring for residents infected with MDROs from those caring for non-infected residents, contributing to cross-contamination. As a result, numerous residents became infected with various MDROs, including carbapenem-resistant Pseudomonas aeruginosa (CRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), and New Delhi metallo-beta-lactamase (NDM) producing organisms. The report details the medical histories and conditions of affected residents, many of whom had complex medical needs such as ventilator dependence, quadriplegia, and chronic respiratory failure. The cumulative failures led to an Immediate Jeopardy situation, as the facility's actions placed residents at significant risk of harm.
Failure to Develop Comprehensive Care Plans for Residents with NDM Infection
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents who tested positive for an antibiotic-resistant infection known as Carbapenemase-Producing Organisms (CPO), specifically the New Delhi metallo-β-lactamase (NDM) enzyme. Despite laboratory reports confirming NDM infection for these residents, their care plans did not address this specific infection. The residents involved had complex medical histories, including conditions such as anoxic brain damage, acute respiratory failure, cardiac arrest, critical illness myopathy, COPD, tracheostomy status, cervical spine fusion, and ventilator dependence. The absence of individualized care plans for their NDM infection was identified through observation, interview, and record review. During interviews, the DON acknowledged that care plans should have been developed for all residents with infections, especially during an outbreak, but stated that the facility focused only on isolation types rather than the specific infections. Review of the facility's policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and should be updated as residents' conditions change. However, this process was not followed for the residents with NDM infection, resulting in a lack of person-centered care planning for their identified needs.
Controlled Substance Documentation and Security Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances for two residents, leading to potential misuse or diversion of medications. For Resident 49, alprazolam 0.25 mg was recorded on the Controlled Drug Record (CDR) but not on the Medication Administration Record (MAR) on two separate occasions. This discrepancy was confirmed during interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), who acknowledged the failure to document the medication on both records. The facility's policy requires that controlled medications be documented on the MAR, which was not adhered to in this case. Additionally, for Resident 15, there was a lack of proper documentation for morphine sulfate prescriptions. The CDR and MAR did not match, with only one CDR sheet available for two different morphine orders. This inconsistency was noted by a Registered Nurse (RN) and the DON, who recognized the risk of medication errors due to the mismatch. Furthermore, the medication cart was observed to be unlocked on two occasions, posing a risk of unauthorized access to medications. The facility's policy mandates that medication carts be locked when out of the nurse's view, which was not followed, as observed by an LVN and confirmed by the DON.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to manufacturer specifications and accepted professional principles. Two containers of acetylcysteine, used for breaking up mucus in lung disease patients, were found without an open date in the medication refrigerator for two residents. This oversight was confirmed by an LVN, who acknowledged the risk of administering ineffective medication if not labeled with an open date. Additionally, an unopened insulin pen was improperly stored in a medication cart instead of the refrigerator, contrary to the facility's policy and manufacturer guidelines, which could lead to reduced effectiveness. Further observations revealed that oral medications were stored in the same compartment as eye drops in a medication cart, increasing the risk of administering medications via the wrong route. Four bottles of artificial tears were labeled only with room numbers, posing a risk of being administered to the wrong resident if room assignments changed. These labeling and storage deficiencies had the potential to result in residents receiving incorrect or expired medications.
Incompetence in Kitchen Staff Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were competent in their job duties, leading to potential contamination risks. A cook demonstrated an incorrect method for calibrating a food thermometer by adding hot water to a mixture of cold water and ice, which was not in line with the facility's policy. The Registered Dietician (RD) confirmed that this method was incorrect and could result in inaccurate temperature readings, which are crucial for food safety. Additionally, a dietary aide (DA) incorrectly tested the sanitizer strength in the dish machine by using a chlorine test strip on the bottom of the machine instead of on a wet plate, as required by the facility's policy. The RD confirmed that the method used by the DA was improper and did not comply with the established procedures for ensuring the correct sanitizer concentration. Furthermore, there was confusion among the kitchen staff regarding the preparation and use of sanitizing solutions. A dietary aide used a spray bottle with a sanitizer solution that was not properly labeled and did not know the correct concentration. Another aide prepared the solution but was unsure of its strength, and a Territory Representative confirmed that the solution was too concentrated and not suitable for food contact surfaces. This lack of knowledge and adherence to proper procedures posed a risk of contamination for the 22 residents receiving food from the kitchen.
Expired Seasonings and Unclean Equipment in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by storing and using expired seasonings and maintaining unclean kitchen equipment. During an observation in the kitchen, eight different dry seasonings were found to be either expired or beyond their use-by dates. These seasonings, including sweet basil, tarragon, ground cloves, crushed Italian seasoning, Cajun seasoning, ground ginger, ground black pepper, and ground cinnamon, were stored on a wall shelf behind the cooking area. The Registered Dietician (RD) confirmed the expiration and use-by dates and acknowledged that kitchen staff should dispose of seasonings past their expiration dates, as per the facility's food storage chart. Additionally, a tabletop can opener was observed to be unclean, with a white and deep brown residue build-up on its gear and cavity. The RD confirmed that the can opener was dirty and should be cleaned after each use. The facility's policy and procedure on sanitization, dated 2008, requires that all equipment be washed to remove or completely loosen soils. These deficiencies placed 22 residents who received food from the kitchen at risk for foodborne illnesses.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, Resident 40 and Resident 59, who were unable to maintain personal hygiene and grooming due to their medical conditions. Resident 59, who was admitted in March 2024, had diagnoses including encephalopathy and traumatic hemorrhage of the cerebrum, and was totally dependent on staff for personal hygiene. Observations revealed that Resident 59 had long, thick facial hair, and a Certified Nurse Assistant (CNA) from an agency was unsure if shaving was her responsibility. The Licensed Vocational Nurse (LVN) confirmed that CNAs were responsible for maintaining Resident 59's grooming, and the family representative expressed that Resident 59 would have preferred to be shaved occasionally. Similarly, Resident 40, admitted in January 2024 with encephalopathy and acute and chronic respiratory failure with hypoxia, was also totally dependent on staff for personal hygiene. Observations showed that Resident 40 had long, thick facial hair, and the LVN noted that this could lead to skin irritation or breakdown. The Director of Nursing (DON) stated that CNAs were expected to maintain residents' personal hygiene and grooming, and acknowledged the risk of compromised skin integrity and dignity due to long facial hair. The facility's policy indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene.
Failure to Change Tracheostomy Tie as Ordered
Penalty
Summary
The facility failed to provide proper tracheostomy care for a resident, identified as Resident 59, by not changing the tracheostomy tie daily as ordered by the physician. The resident, who was dependent on a ventilator, had a tracheostomy tie that was last changed on 6/14/24, despite the physician's order requiring it to be changed every shift, as needed if soiled or dislodged, and after a shower. This oversight was observed during a survey on 7/9/24, when the tracheostomy tie was found to be dated nearly a month prior. Interviews with the Registered Nurse Supervisor and the Respiratory Therapist Director revealed discrepancies in the facility's practice and the physician's order. The RN Supervisor acknowledged that the tracheostomy ties should be changed daily, while the RT Director stated they should be changed every 2-3 days. Both acknowledged the risk of skin irritation and infection due to the failure to change the tracheostomy tie as required. The facility's policy, dated 2001, also indicated that tracheostomy care should be provided at least once daily for established tracheostomies.
Failure to Implement Pharmacist's Recommendations for Medication Indication
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations regarding the medication regimen of Resident 19, who was receiving quetiapine. The consultant pharmacist's Medication Regimen Review (MRR) for April 2024 recommended updating the diagnosis to 'dementia with behaviors - biting' to justify the use of quetiapine. However, as of July 10, 2024, these recommendations had not been reviewed by the physician, and the resident continued to receive quetiapine without the correct indication documented. During interviews and record reviews, the Director of Nursing (DON) confirmed that the pharmacist's recommendations were not implemented for Resident 19. The facility's policy and procedure for Medication Regimen Review and Reporting requires that recommendations be acted upon within 30 days, but this was not adhered to. The DON acknowledged the importance of having correct indications for medication use to ensure resident safety and prevent unnecessary side effects.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident for 13 residents occupying 6 multi-bed rooms. During an observation, it was noted that the rooms had less than the mandated space per bed, with measurements ranging from 72.87 to 79.75 square feet per bed. Despite this deficiency, there was sufficient space for the provision of care, and no heavy equipment was present that could interfere with residents' care. Residents had adequate personal space and privacy, and there were no complaints or negative consequences reported due to the decreased space.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Leandro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| All Saint's Maubert | 0 mi | ★★★★★ | 20 | 0 |
| Alameda County Medical Center D/p Snf | 0.2 mi | ★★★★★ | 0 | 0 |
| Kaiser Permanente Post-acute Care Center | 1 mi | — | 0 | 0 |
| Washington Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Valley Pointe Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 20 | 0 |
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