The Villas At Saratoga Skilled Nsg & Assisted Lvg
THE VILLAS AT SARATOGA SKILLED NSG & ASSISTED LVG in SARATOGA, CA — inspection on August 12, 2025.
Found 2 citations. 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
Based on interview and record review the facility failed to timely suspend two certified nurse assistants (CNA) who had an allegations of resident mistreatment in accordance with their abuse policy for two of two sampled residents (Residents 1 and 2).
This failure had the potential to place residents at risk for further mistreatment should the allegation be proven.Findings:1.Review of Resident 1's Nurses Notes, dated 5/17/25 at 1:50 p.m., indicated the resident reported CNA A and told Resident 1 to shut up and mind your own business on 5/16/25.
The same note indicated Resident 1 stated there were a few other times when the resident was verbally disrespected by the same CNA A and she felt belittled.
During an interview on 7/2/25 at 12:29 p.m., the registered nurse (RN) B stated when she learned about Resident 1's allegation she did not suspend CNA A.2.Review of Resident 2's Nurse's Notes, dated 6/13/25 at 6:47 p.m. indicated the resident reported to therapy staff that she was punched and poked on the sides of her abdomen while being changed by CNA B when Resident 2 cannot urinate past 11 p.m.
During an interview on 7/3/25 at 12:15 p.m., licensed vocational nurse C (LVN C) stated when she received a message from a therapist regarding the above incident, she changed the assignment and did not suspend the CNA B.During an interview on 7/31/25 at 10:50 a.m., the director of staff development (DSD, person who develops training programs and onboards new staff) stated when a staff member was accused of abusing a resident, licensed nurses were take a statement from the staff member, report the incident and send the staff member home immediately.
Review of the Abuse, Neglect or Misappropriation - Report and Investigating policy, revised September 2024, indicated any employee who was accused of resident abuse was to be placed on leave with no resident contact until the investigation was complete.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villas at Saratoga Skilled Nsg & Assisted Lvg
20400 Saratoga-Los Gatos Rd Saratoga, CA 95070
SUMMARY STATEMENT OF DEFICIENCIES
swiped food from another resident's room and explanation was given to a family member.
There was no care plan developed addressing Resident 3's behavior of wandering into other resident rooms.Review of Resident 3's Change in Condition Evaluation (CICE), dated 4/6/25 at 4:01 p.m., indicated a staff reported a family member saw Resident 3 walking outside the facility and was found on Oak Street and brought back to St [NAME] Station.Review of Resident 3's Elopement Evaluation note, dated 4/10/25 at 2:32 p.m., indicated the resident had a history of elopement at home, had wandering behavior likely to affect safety or well-being of self and others and was identified to be at high risk for elopement. A plan was made to apply personal safety alarm device (wander guard), document specific behaviors on the behavior log, monitor location frequently and to notify staff. A care plan was developed on 4/10/25 addressing Resident 3's elopement an approach to monitor resident whereabout, especially during meals, shift changes, or when visitors were presentThere was no interdisciplinary team (IDT, health care members who meet to discuss and plan residents' care) about the 4/6/25 elopement.Review of Resident 3's Medication Administration Record (MAR) indicated she was monitored once a shift on the day, evening and night shift for elopement and wander guard to left wrist from 4/11/25 to May 2025.
The MAR did not specify when, such as meal times.Review of Resident 3's CICE, dated 5/13/25 at 8:40 p.m., indicated at 7:45 p.m. the resident eloped from the facility again when she was noted to be missing and found on Oak Street around 8:15 p.m.Review of Resident 3's IDT notes, dated 5/15/25 at 8:12 a.m., indicated the resident was alert to self/name only, had a diagnosis of dementia, had previous attempts to leave the facility including trying to open doors, was found exiting from the elevator and wander guard was active and linked to the unit exit door.
The resident was unable to recall the incident, was placed on hourly monitoring with frequency checks and directed staff to assess for triggers such as pain, loud noises that may cause wandering.During a tour with the maintenance director (MD) and environmental service director (EVS) on 6/30/25 at 4 p.m., it was observed St [NAME] Station had 4 exits, including an elevator from the second floor.
The elevator, and an exit from St [NAME] second floor leading to stairs and an exit at St [NAME]'s first floor that led out from the building did not have alarms alerting staff of residents placed on wander guard.
The first floor exit at St [NAME] was not alarmed and led to a gate approximately 20 feet away that led to a parking lot. To get to Oak St., a person had to travel down a hill over a block long.
During an interview on 6/30/25 at 4:15 p.m., the MD stated Resident 3 was trying to go into the elevator frequently and there currently was no elevator alarm.During an interview on 7/30/25 at 1:19 p.m., the medical record director (MRD) who reviewed the record stated there should have been an elopement care plan developed by the next day (4/7/25), and an IDT note addressing the 4/6/25 elopement and said her job included auditing medical records for completeness.During an interview on 7/3/25 at 11:55 a.m., the MD stated the facility just initiated a wandering log to check the alarms and there was no policy or manufacturer's instruction addressing the maintenance and checking of wander guard function.
During an interview on 7/30/25 at 2:34 p.m., the DON stated a care plan should have been develop when a problem arose such as a change in condition
During a follow-up telephone interview with the DON on 7/31/25 at 10:15 a.m., a request was made for Resident 3's behavior and frequent monitoring log as documented in the 4/10/25 Elopement Evaluation and assessment of resident triggers for elopement as noted in the 5/15/25 IDT notes and the information were not provided.Review of the Care Planning - Interdisciplinary Team policy, revised March 2022, indicated the IDT was responsible for the development of resident care plan and did not specify the timeframe i.e. timeframe after when a resident problem was identified.
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