Health inspection·December 20, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to treat three of 18 sampled residents (Residents 25, 45, and 64) with respect and dignity when: Residents Affected - Few 1. The certified nurse assistant (CNA) stood beside the residents to assist with their meals, and 2. Resident 25's urine bag (bag that is attached to a tube that is connected to the bladder) was not covered. These failures resulted in not ensuring residents were treated with respect and dignity, and could potentially affect the residents' self-worth. Findings 1.During a dining observation on 12/16/24 at 12:37 a.m., the CNA G assisted Resident 45 with her meal. The CNA G was standing while trying to feed Resident 45. At 12:40 a.m., the CNA G assisted Resident 64 with her meal. The CNA G was standing while feeding Resident 64. During an interview with the CNA G on 12/16/24 at 2:01 p.m., the CNA G confirmed the above observations and stated she should sit down when providing assistance to residents during meals. During an interview with Licensed Vocational Nurse (LVN) H, on 12/16/24 at 2:05 p.m., the LVN H stated staff assisting Residents during meals should be sitting down. During a review of the facility 's policy and procedure (P&P) titled, Assistance with Meals, revised March 2022, the P&P indicated, Resident shall receive assistance with meals in a manner that meets the individual needs of each resident. Dining Room Resident :3. Resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity, .a. not standing over resident while assisting them with meals. 2. During an observation on 12/16/24 at 10:50 a.m., Resident 25's foley catheter bag was seen hanging on the bedframe, and the bag was visible. The bag was noted to be visible at multiple viewing angles. During an interview with the Director of Nursing (DON) on 12/19/24 at 11:29 a.m., the DON stated the foley catheter bags should either have a dignity sleeve covering them, or for anyone with a foley Page 1 of 35 055435 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0550 catheter, to have a foley catheter bag that has a built in cover on the front. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055435 Page 2 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure three of 4 residents (Residents 16, 62 and 84) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatments patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in the inability to make medical decisions, and could lead to the delivery of unnecessary or inappropriate medical services. Findings: a. Review of Resident 16's face sheet (FC, a document that gives a resident's information at a quick glance) indicated, Resident 16 was admitted to facility on 7/8/15. Review of Resident 16's clinical record, indicated, there was no documentation of whether Resident 16 had an advance directive. Resident 16's POLST form's section D, which was designed to indicate whether the resident had an advance directive, was not completed. During a concurrent interview and record review with social service director (SSD) on 12/19/24 at 11:48 a.m., for AD for Resident 16, the SSD confirmed there was no AD currently in place for Resident 16's POLST form section D. The SSD further stated the facility has verbal power of attorney but not translated to the POLST section D. b. Review of Resident 62's FC indicated Resident 62 was admitted to the facility on [DATE]. Review of Resident 62's clinical record, indicated, there was no documentation of whether or not Resident 62 had an advance directive. Resident 62's POLST form's section D, dated 11/15/24, was not completed. During a concurrent record review interview with social service director (SSD) on 12/19/24 at 11:40 a.m., for an AD for Resident 62, the SSD confirmed there was no AD for Resident 62. The SSD stated the facility should have made attempts to obtain and discussed the importance of health care directive. c. Review of Resident 84's FC indicated Resident 84 was admitted to the facility on [DATE].Review of Resident 84's clinical record, indicated, there was no documentation of whether or not Resident 84 had an advance directive. Resident 84's POLST form's section D, dated 11/22/24, was reviewed and was not completed. During a concurrent record review interview with social service director (SSD) on 12/19/24 at 11:44 a.m., for an AD for Resident 84, the SSD confirmed there was no AD for Resident 84. The SSD stated the facility should fill up and update once they have the AD section D. During an interview with director of nursing (DON) on 12/19/2024 at 11:29 a.m., the DON confirmed, there were no advance directives for Residents 16, 62 and 84. The DON also confirmed, section D of the residents' POLST forms were not completed. The DON further stated for the POLST, the Interdisciplinary team (IDT) goes over it during the admission conference, and asks if the family has an AD, and includes it in the resident' files. 055435 Page 3 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy and procedure (P&P) titled, Advance Directives/Individual health Care Instructions, revised September 2022, the P&P indicated, Prior to or upon admission of a resident, the social services director or designee inquires of the resident his /her family members and /or her legal representatives, about the existence of any written advance directives. If the resident does not have an Advance Directive . 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. 055435 Page 4 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan for one of 18 sampled residents (Resident 20) to address the use of Clopidogrel (medication used to prevent blood clots). This failure had the potential to compromise the facility's ability to implement interventions to maintain the resident's well-being. Findings: Review of Resident 20's clinical record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease (or coronary heart disease, a condition that occurs when plaque builds up in the walls of arteries, making it difficult for blood to flow) of Native Coronary Artery without Angina Pectoris (chest pain or discomfort due to CHD), and drug induced Cushing's syndrome (a rare, chronic condition that occurs when the body produces too much cortisol [a hormone that helps the body respond to stress, maintain blood pressure , and regulate inflammation]). Review of Resident 20's Physician Order, dated 10/11/24 indicated, Clopidogrel Bisulfate 75 milligrams (mg, unit of dose measurement) oral tablet. Give 1 tablet by mouth one time a day for blood clotting disorder. Review of Resident 20's clinical record indicated there was no care plan to address the use of Clopidogrel. During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 12/20/24 at 10:54 a.m., the ADON confirmed Resident 20 had no care plan for the use of Clopidogrel. The ADON stated it should be part of the patients care and have the interventions for resident treatment. During an interview and concurrent record review with the Director of Nursing (DON) on 12/19/2024 at 10:44 a.m., the DON confirmed there was no care plan addressing Resident 20'a use of Clopidogrel. The DON acknowledged there should have been a care plan. Review of the facility's policy and procedure (P&P) titled, Care Plan, comprehensive Person -Centered, revised date March 2022, indicated, A comprehensive, person-centered plan that includes measurables objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan a. includes measurables objectives and timeframes. 055435 Page 5 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to provide care according to facility policy and procedure for one of 24 sampled residents (Resident 70) when a registered nurse (RN B) did not have the running of the continuous tube feeding (nutrition that is given through a tube that goes directly into the stomach) placed on hold when they put Resident 70's head of the bed flat to carry out a pressure ulcer treatment. This failure had the potential for enteral feeding complications that could cause harm to this resident. Findings: During a concurrent observation and interview on 12/19/24 at 6:51 AM, RN B placed Resident 70's head of the bed flat from its previous 30 degrees elevated position with tube feeding machine running the entire time. When asked about should be done with continuous tube feedings when putting the resident's head of the bed flat, RN B said, We hold the tube feeding. The feeding is paused. During an interview with the director of nursing (DON) on 12/19/24 at 11:29 AM, the DON said continuous tube feedings should be held when providing care. Review of facility policy and procedure titled Enteral Tube Feeding via Continuous Pump, last revised November 2018, indicated [ .]Position the head of the bed at 30-45 (semi-Fowler's position) for feeding, unless medically contraindicated [ .] 055435 Page 6 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis (procedure to remove waste and excess fluid from the body) communication reports were complete (NDCRs) for one of 18 sampled residents (Resident 62). This failure had the potential to put Resident 62 at risk for complications. Residents Affected - Few Findings: Review of Resident 62's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (the kidney's no longer functioning on a permanent basis) and hypertensive (high blood pressure) chronic kidney disease with stage 5 chronic kidney disease. Resident 62's NDCRs dated 11/19/24, 11/23/24, and 12/12/24 were reviewed. The portion of the NDCRs to document Resident 62's post dry weight was left blank. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) H on 12/18/24 at 10:44 a.m., LVN H reviewed Resident 62's NDCRs dated 11/19/24, 11/23/24, and 12/12/24 and confirmed they were incomplete. LVN H stated the NDCRs should be filled out completely and if the dialysis center did not fill out the form it should be sent back or communicated to the dialysis center to complete the form. During a concurrent interview and record review with the Director of Nursing (DON) on 12/20/24 at 3:10 p.m., the DON confirmed the three NDCR forms were incomplete, as they had no post dry weight. The DON stated the NDCRs should be filled out completely; and, if the dialysis center did not fill out the form, it should be communicated to the dialysis center right away. During a review of the facility's policy and procedure (P&P) titled, End Stage Renal Disease, Care of a Resident with, revised September 2010, the P&P indicated, Resident with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. 4. Agreements between this facility and contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. How information will be exchanged between the facilities. 055435 Page 7 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their bed rail (adjustable rigid bars attached to the side of a bed) policy for 12 of 18 sampled residents (Residents 2, 4, 8, 16, 20, 23, 33, 43, 51, 67, 70 and 82). The facility failed to follow their bed rail policy for use of grab bars when: 1. For Resident #2 there was no physician order for the use of grab bars; 2. For Resident #43 and Resident 67 there was no physician order for the use of grab bars; 3. For Residents # 23, 33, 8, and 82, there were no care plans for the use of grab bars; 4. For Resident # 70, there was no physician order or care plan for the use of grab bars; 5. For Resident # 4, and 20 there was no physician order or care plan for the use of grab bars; 6. For Resident # 4, 16, 20, and 51 there were no care plans for the use of grab bars; These failures had the potential to compromise the residents' health and safety. Findings: 1. During an observation on 12/16/24 at 1:08 p.m., in Resident 2's room, Resident 2 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. Review of Resident 2's Bed Rail Use Evaluation, dated 11/18/24, indicated, the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was to assist Resident 2 with bed mobility and for positioning assistance. Review of Resident 2's physician orders indicated there were no physician order for the use of the grab bars for Resident 2. During an interview and concurrent record review with the director of nursing (DON) on 12/18/24 at 10:50 a.m., she confirmed Resident 2 was using grab bars on the bed, and confirmed there was no physician order for the use of the grab bars. The DON further stated residents who have grab bars in use should have a physician order in place for it. 2. During an observation on 12/16/24 at 9:58 a.m., in Resident 43's room, Resident 43 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. Review of Resident 43's Bed Rail Use Evaluation, dated 9/28/24, indicated the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was for positioning assistance. During an observation on 12/16/24 at 10:28 a.m., in Resident 67's room, Resident 67 had grab bars, bilaterally, on the top portion of the bed. The grab bars were fixed in the upright position. 055435 Page 8 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 67s Bed Rail Use Evaluation, dated 10/2/24, indicated, the use of bed rails is recommended at all times when resident is in bed. The rationale for use of bed rails was to assist Resident 67 with bed mobility and for positioning assistance. Review of Resident 43 and Resident 67's physician orders indicated there were no physician orders for the use of the grab bars for Resident 43 and Resident 67. and 5.During an observation in Resident 4's room on 12/16/24 at 10:22 a.m., Resident 4 had bilateral (both side) grab bars. During a review of Resident 4's physician orders indicated there was no physician order for the use of grab bars. During an observation in Resident 20's on 12/16/24 at 9;47 a.m., Resident 20 had bilateral (both side) grab bars. During review of Resident 20's physician orders indicated there was no physician order for the use of grab bars. During a concurrent interview and record review with Minimum Data Set Director (MDSD) on 12/19/24 at 11:14 a.m., the MDS confirmed there were no physician orders for the use of grab bars for Resident 4 and 20. During a concurrent interview and record review with DON on 12/19/24 at 4:39 p.m., DON confirmed no physician order for the used of grab bar for Resident 4 and 20. The DON further stated physician order should be entered and bedrail evaluation done quarterly. 6.During an observation in Resident 4's room on 12/16/24 at 10:22 a.m., Resident 4's had bilateral (both side) grab bar. During a review of Resident 4's care plan indicated there was no care plan for the use of the grab bars. During an observation in Resident 16 on 12/16/24 at 11:03 a.m., Resident 16's had bilateral (both side) grab bar. During review of Resident 16's physician order, dated 2/12/24 indicated Resident 16 had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility every shift. During review of Resident 16's care plan indicated there was no care plan for the use of the grab bars During an observation in Resident 20's ([NAME]) on 12/16/24 at 9;47 a.m., Resident 20's had bilateral (both side) grab bar. During review of Resident 20's care plan indicated there was no care plan for the use of the grab bars 055435 Page 9 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0700 Level of Harm - Minimal harm or potential for actual harm During an observation in Resident 51's room on 12/16/24 at 11:15 a.m., Resident 51's had bilateral (both side) grab bar. During review of Resident 51's physician order, dated 8/16/24, indicated Resident 51 had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility every shift. Residents Affected - Some During review of Resident 51's care plan indicated there was no care plan for the use of the grab bars. During a concurrent interview and record review with Minimum Data Set Director (MDSD) on 12/19/24 at 11:14 a.m., the MDS confirmed there was no care plans for the use of grab bars for Resident 4,16, 20 and 51. During a concurrent interview and record review with DON on 12/19/24 at 4:39 p.m., DON confirmed no care plan for the use of grab bar for Resident 4 ,16, 20 and 51. The DON further stated there should be a care plan specific for the grab bar. During a review of the facility's policy and procedure (P&P) titled, Use of Side Rails /Bed Rails,undated , the P&P indicated, Purpose: The purpose of these guidelines are to ensure the safe use of side rails/bed rails as resident mobility aids 5. The use of side rails /grab bars will be addressed in the resident's care plan .11. Facility staff , in conjunction with the Attending Physician , will evaluate and documents the resident risk for injury . 3. During an observation on 12/16/17/24 at 12:37 PM, in Resident 8's room, Resident 8 had two grab bars fixed on the bed in the upright position. Review of Resident 8's physician order, dated 7/8/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 8's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 1:54 PM, in Resident 23's room, Resident 23 had two grab bars fixed on the bed in the upright position. Review of Resident 23's physician order, dated 11/5/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 23's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 9:47 AM, in Resident 33's room, Resident 33 had two grab bars fixed on the bed in the upright position. Review of Resident 33's physician order, dated 9/6/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 33's care plan indicated there was no care plan for the use of the grab bars. During an observation on 12/16/17/24 at 10:01 AM, in Resident 82's room, Resident 82 had two grab bars fixed on the bed in the upright position. 055435 Page 10 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 82's physician order, dated1121/24 indicated he had an order for Bilateral grab bar up when in bed to assist Resident in bed mobility q shift. Review of Resident 82's care plan indicated there was no care plan for the use of the grab bars. During an interview and concurrent record review with the DON on 12/19/24 at 11:29 a.m., the DON confirmed Residents 8, 23, 33 and 82 were using grab bars on their beds, and had care plans that were initiated on 12/18/24, during the survey period. The DON further stated residents who had bed rails in use should have a care plan for the use of grab bars. 4. During an observation on 12/16/17/24 at 9:47 a.m., in Resident 70's room, Resident 70 had two grab bars fixed on the bed in the upright position. Review of Resident 70's physician orders indicated there was no physician order for the use of grab bars. Review of Resident 70's care plan indicated there was no care plan for the use of the grab bars. During an interview and concurrent record review with the DON on 12/19/24 at 11:29 a.m., the DON confirmed Resident 70 was using grab bars on his bed, and had a physician order dated 12/18/24, and a care plan that was initiated on 12/18/24, during the survey period. The DON further stated residents who had bed rails in use should have a physician order and a care plan for the use of grab bars. 055435 Page 11 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, and record review, the facility failed to ensure accurate accountability of controlled drugs (those with high potential for abuse and addiction), when there were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 3 out of 6 residents (Residents 33, 9 and 28). This failure had the potential for abuse or misuse of controlled drugs. Findings: During the survey, the CDR (or count sheet) for six residents receiving PRN (as needed) controlled medications were requested for review. During an interview with the Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) on 12/17/24 at 1:54 p.m., the ADON stated when a resident requests for a PRN (as needed) controlled medication, the nurse assesses the resident for pain severity; reviews the physician's order, and administers the medication if it's within the appropriate administration time to give the medication, removes the medication from the medication cart; signs it out of the count sheet; administers the medication to the resident; and documents the administration on the resident's MAR. a. A review of Resident 33's clinical record indicated a physician's duplicate orders, dated 9/6/24 and 11/15/24, for tramadol (potent narcotic used to treat moderate to severe pain) 50 mg (milligrams, unit of measure) tablet, give 1 tablet by mouth every 12 hours as need for moderate to severe pain. During a concurrent interview and record review with the ADON and the DSD on 12/17/24 at 1:54 p.m., a review of Resident 33's CDR for tramadol HCL 50 mg and the November 2024 MAR indicated on 2 occasions, the nursing staff signed out of the count sheet but did not document on the MAR to show it was administered to the resident as follows: -11/17/24 at 12:01 a.m. -11/26/24 at 10:55 a.m. During this interview and record review, the ADON and the DSD confirmed the above findings. They also reviewed Resident 33's progress notes and stated they could not find documented evidence to show the medication was administered to the resident for the above dates. b. A review of Resident 9's clinical record indicated a physician's order, dated 10/13/24, for hydrocodone-acetaminophen (brand name Norco, a potent narcotic for pain) 5/325 mg oral tablet, give 1 tablet by mouth every 6 hours as needed for moderate pain. During a concurrent interview and record review with the ADON and the DSD on 12/17/24 at 2:17 p.m., a review of Resident 9's CDR for hydrocodone-acetaminophen 5/325 mg and the November 2024 MAR indicated, the nursing staff signed out of the count sheet but did not document on the MAR to show it was administered to the resident on 11/4/24 at 1305 (1:05 p.m.). During this interview and record review, the ADON and DSD confirmed the above finding. They also 055435 Page 12 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed Resident 9's progress notes and stated they could not find documented evidence to show the medication was administered to the resident. c. A review of Resident's clinical record indicated a physician's order, dated 3/25/22, for hydrocodone-acetaminophen 5/325 mg oral tablet, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain; and hydrocodone-acetaminophen tablet 5/325 mg, take 2 tablets by mouth every 6 hours as needed for severe pain, dated 3/31/22. During a concurrent interview and record review with the ADON and DSD on 12/17/24 at 2:21 p.m., a review of Resident 28's CDR for hydrocodone-acetaminophen 5/325 mg and the December 2024 MAR indicated, the nursing staff signed out of the count sheet but did not document on the MAR to show it was administered to the resident on 12/13/24 (no time documented). During this interview and record review, the ADON and the DSD confirmed the above finding. They also reviewed Resident 28's progress notes and stated they could not find documented evidence to show the medication was administered to the resident. A review of the facility's policy and procedures (P&P) titled Administering Medications, revised April 2019, indicated, The individual administering the medication records in the resident's medical record: a. The date and time the medication was administered . g. The signature and title of the person administering the drug. A review of the facility's P&P titled Charting and Documentation, dated July 2022, indicated in part, The following information is to be documented in the resident's medical record: 2a. Objective observations; b. Medications administered . 3. Documentation in the medical record will be objective (not opinionated or speculative) complete, and accurate. 055435 Page 13 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days for one of six sampled residents (Resident 2). This failure had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects. Findings: Review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental capacity affecting daily function), delusional disorders (mental health condition in which a person can't tell what's real from what's imagined), and major depressive disorder. Review of Resident 2's physician order dated 9/26/24 indicated Seroquel (antipsychotic medication that calms the mind and reduces anxiety) 25 milligrams (mg, unit of dose measurement). Give 12.5 mg by mouth every 12 hours as needed for psychosis (a mental disorder characterized by a disconnection from reality) as manifested by agitation or aggression. There was no stop date indicated on the physician order, and the stop date was transcribed as indefinite. Review of Resident 2's medication administration record (MAR) indicated Resident 2 received PRN Seroquel 12.5 mg eleven times in October 2024, eleven times in November 2024, and one time in December 2024. These 23 prn dosages were administered beyond the 14-day limitation for psychotropic medications ordered for prn usage. During an interview and concurrent record review with director of nursing (DON) on /18/24 at 9:07 a.m., she stated PRN psychotropic medications should be limited to 14 days unless the physician provides a rationale to extend the PRN use beyond the 14 days. The DON confirmed Resident 2's Seroquel physician order, dated 9/26/24, had no stop date and she stated the PRN Seroquel cannot be ordered indefinitely. The DON stated the order should be for 14 days only and then re-evaluated by the physician. The DON reviewed Resident 2's MAR and confirmed licensed nurses administered PRN Seroquel 12.5 mg to Resident 2 eleven times in October 2024, eleven times in November 2024, and one time in December 2024. The DON confirmed licensed nurses administered PRN Seroquel to Resident 2 for 3 months. The DON confirmed these administration dates were beyond the 14-day limitation for PRN psychotropic medications. Review of the facility's policy, Psychotropic Medication Use, dated July 2022, indicated PRN orders for psychotropic medications are limited to 14 days .If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 055435 Page 14 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 8.82% when three medication errors occurred out of 34 opportunities during the medication administration for two of four residents (Residents 18 and 89). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications or adverse effects, compromising their health. Residents Affected - Few Findings: 1. During a medication administration observation on 12/16/24 at 9:14 a.m. with Registered Nurse (RN) C, RN C was observed preparing twenty medications for Resident 89 including an Arnuity Ellipta inhaler (medication used to treat the symptoms of asthma (an inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath). On 12/16/24 at 9:35 a.m., at the bedside of Resident 89, RN C gave the Arnuity Ellipta inhaler to the resident. Resident 89 self-administered two puffs of the oral inhaler simultaneously one after another. On 12/16/24, a review of Resident 89's clinical record indicated a physician's order, dated 12/9/24, for Arnuity Ellipta 100 MCG/ACT (unit of measurement/to cause the inhaler to spray) aerosol powder, inhale 1 puff orally one time a day for asthma. Rinse mouth with water after each use. During a concurrent interview and record review on 12/16/24 at 9:41 a.m. with RN C, RN C verified the physician's order was for 1 puff of the Arnuity Ellipta inhaler instead of 2 puffs. RN C stated, I should have taken the inhaler from the resident after the first dose. 2. During a medication administration observation on 12/16/24 at 10:12 a.m. with RN B, RN B was observed preparing ten medications for Resident 18, including an oral inhaler containing a combination of budesonide and formoterol (budesonide belongs to a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways. Formoterol belongs to the class of drugs known as long-acting beta agonists. It works by relaxing the muscles around the airways so that they can open up to allow easier breathing) 80 mcg (micrograms-a unit of measurement) /4.5 mcg. On 12/16/24 at 10:33 a.m., at the resident's bedside, RN B was observed administering 1 puff of the oral inhaler. Resident 18 began talking immediately after inhaling the first puff. Mist was observed escaping his mouth while speaking. RN B asked the resident to drink some cranberry juice before and after giving the second puff of the inhaler. RN B did not instruct the resident to inhale deeply and to hold his mouth around the inhaler after each puff. RN B did not ask the resident to rinse his mouth with water after the inhaler administration. During an interview on 12/16/24 at 10:36 a.m., RN B verified she did not ask Resident 18 to hold his mouth around the inhaler during the administration of the medication. RN B stated, He does not like to rinse his mouth with water, so I give him cranberry juice to drink instead. On 12/16/24, a review of Resident 18's clinical record indicated a physician's order, dated 5/19/22, for Symbicort Aerosol (budesonide-formoterol fumarate) 80-4.5 MCG/ACT (micrograms per actuation) 2 puffs inhale orally two times a day for COPD (a disease that affects airflow in the lungs and makes 055435 Page 15 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0759 it difficult to breathe), Rinse out mouth with water thoroughly after use. Level of Harm - Minimal harm or potential for actual harm During an interview and review of facility's policy for administering medications through an inhaler on 12/17/24 at 11:39 a.m. with the Director of Nursing (DON), the DON verified the staff should follow the facility's policy and procedure for administering medications through an inhaler. The DON stated, The resident has to rinse with water, giving cranberry juice to drink is not a replacement for rinsing with water. Residents Affected - Few A review of the facility's policy and procedures (P&P) titled Administering Medications through a Metered Dose Inhaler, revised October 2010, indicated, Administer medication . d. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. e. Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around the mouthpiece. f. Firmly depress the mouthpiece against the medication cannister to administer medication. g. Instruct the resident to inhale deeply and hold for several seconds; h. Remove the mouthpiece from the mouth and instruct the resident to exhale slowly through pursed lips. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Symbicort (budesonide and formoterol fumarate dihydrate), revised 12/2017, indicated: After inhalation, the patient should rinse the mouth with water without swallowing. This will help to lessen the chance of getting a fungus infection (thrush) in the mouth and throat. 3. During the medication administration observation above with RN B on 12/16/24 at 10:28 a.m., RN B gave 1 spray of fluticasone (a nasal spray used to prevent and treat allergy symptoms) 50 mcg into each opening of the nose of Resident 18. Shortly after the medication observation, a review of Resident 18's clinical record indicated a physician's order, dated, 2/27/21, for fluticasone propionate suspension 50 MCG/ACT 2 sprays in each nostril one time a day for postnasal drip give 2 sprays in each nostril. During an interview and review of Resident 18's clinical record on 12/16/24 at 1:57 p.m., RN B verified the physician's order was for 2 sprays of the fluticasone propionate suspension into each nostril and that she gave Resident 18 one spray in each nostril. A review of the facility's P&P titled, Administering Medications, revised April 2019, indicated: Medications are administered in accordance with prescriber orders, including any required time frame. 055435 Page 16 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observations, staff interviews, and document reviews, the facility failed to ensure overall dietetic services systems for food safety and sanitation were met, according to standards of practice and facility policy. This failure exposed the residents to contaminants (potentially harmful substances) in foods and unsanitary practices, which could have further compromised their nutritional status. The facility census was 84. Cross reference F802, F803, F804, F808, F812, and F908 Findings: During the initial kitchen tour on 12/16/24 starting at 9:07 A.M., multiple observations of unsanitary and unsafe equipment cleaning and food production practices in dietetic services were observed, including: the lack of kitchen cleanliness monitoring, lack of dish machine sanitizing monitoring, lack of recent kitchen staff food safety training, lack of kitchen staff following standardized recipes and therapeutic menus, and lack of an emergency menu for therapeutic diets. 1) Food Safety Storage and Production-Preparation: a. During the initial kitchen tour observation on 12/16/24 at 9:08 A.M., a two-door reach-in meat refrigerator thawing red meat did not have an internal thermometer. The Foodservice Director (FSD) stated the refrigerator should have a thermometer inside to monitor the food temperature. b. During an observation and interview on 12/16/24 at 9:30 A.M., a [NAME] (CK-K) prepared eleven pureed meals by blending 2 cups of tap water with three chopped salmon fillets. CK K then used an unmeasured scooper to add two scoops of thickener from a large white rubber bin ¾ full of thickener to the liquid salmon mixture. The bin with thickener had a label with a smeared written prep date of 5-27-24. CK K stated she did not know how much thickener she added to the mixture because the scooper did not have numbers on it. CK K stirred the liquid mixture with thickener for 30 seconds, then poured it in a small metal pan and placed it in the oven for the lunch meal service. The FSD acknowledged CK K did not use the recipe for pureed meats and stated CK K has been working here for thirty years, so she's been cooking a long time and knows the recipes. FSD also stated the white bin with thickener should have had the current date or should not have been used since it was dated 5/27/24. A review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion yield, 055435 Page 17 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0800 method of preparation, quantities of ingredients, and the time and temperature guidelines . Level of Harm - Minimal harm or potential for actual harm c. Residents Affected - Many During a kitchen observation and interview on 12/16/24 at 3:33 P.M., there was a 32-quart size container of tuna salad with a prep date of 12/16/24 inside the nourishment refrigerator. Diet Aide (DA-L) stated she prepared the tuna this morning at around 11:00 AM but she didn't know the exact time. DA-L stated she mixed a large 10 ounce can of tuna from the dry storage room, a scoop of mayonnaise, and cup of chopped celery together in a clear plastic container. Then DA-L stated she used a green scooper to scoop out some tuna to place on a slices of wheat bread to make about ten tuna sandwiches for the residents. DA-L stated she placed the sandwiches and the container with the remaining tuna salad, inside the refrigerator. DA-L stated she did not take the temperature of the tuna salad before preparing the sandwiches. DA-L stated the sandwiches were served at the lunch meal service that started at 11:45 AM. DA-L stated she was not trained to chill the tuna salad down to 41 degrees Fahrenheit (F) or below before serving the sandwiches. The FSD stated he also did not know the tuna salad should have been cooled to 41 degrees before the sandwiches were made. During an observation on n12/16/24 at 3:36 P.M., the temperature of the dry storage room where the canned tuna was stored, was 63 degrees Farenheit (F). A review of the undated tuna salad sandwich recipe indicated, .Ingredients: Tuna, water packed .celery, finely chopped; Onions, finely chopped; large .eggs, hard cooked, finely chopped; mayonnaise, chilled; wheat bread .Directions: 1. Wash celery and onions well under cold running water. 2. Combine all ingredients for salad and make sandwiches: #12 scoop salad/sandwich. 3 .Prior to serving, store sandwiches covered in refrigerator. Keep chilled at less than 41 degrees F until service . d. During a kitchen observation and interview on 12/17/24 at 11:30 A.M., Diet Aide (DA-M) was observed about to take food temperatures on the lunch tray line. DA-M was asked to demonstrate how to calibrate a thermometer. DA-M filled a cup with water, placed a few ice cubes in it, then placed the thermometer inside the cup. DA-M stated the temperature should be 41 degrees F to calibrate it. The Dietary Assistant Director (AFSD) acknowledged DA-M did not know the correct temperature to calibrate the thermometer should be 32 degrees F. The AFSD stated he calibrates the thermometers at least monthly but does not record on a log. A review of facility policy titled Thermometer Use and Calibration, dated 2023 Policy: Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .Checking the Accuracy and Calibrating .Food thermometers are to be calibrated each week, after one is dropped, or when a thermometer is new. It is recommended to put thermometer calibration on a cook's .sanitation list that must be initialed upon completion . 2) Kitchen Sanitation: a. During the initial kitchen tour observation on 12/16/24 at 9:21 A.M., a dinner meal from the previous night was found inside the kitchen microwave. The dinner meal was a meat entrée, broccoli, rice, and a dinner roll. During the initial tour on 12/16/24 at 9:48 A.M., two big white fans with gray and black lint and 055435 Page 18 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0800 Level of Harm - Minimal harm or potential for actual harm debris were found mounted to the wall facing the food prep counter area. The FSD acknowledged the fans were dirty and could pose a problem if the dirt fell into the food during food prep. On 12/16/24 at 12:15 P.M., an observation of the kitchen microwave was conducted and the dinner meal was inside, unmoved. Residents Affected - Many b. During the initial kitchen tour, an observation and interview was conducted at the dish machine on 12/16/24 at 10:02 A.M with Diet Aide Dishwasher (DA-L) and the FSD. DA-L described how he tested the sanitizing step of the high temperature dish machine by checking if the thermostat on the dish machine reached 180 degrees. DA-L stated sometimes they used a test strip to check the temperature by dipping it into the water solution on the clean side of the machine to see if it turned a different color. The FSD stated DA-L should have placed the test strip on a plate dish, run it through the dish machine, then checked to see if the strip turned black from a gray color. The FSD stated they did not keep a dish machine sanitizing log to monitor the sanitizing temperature level. A review of the facility's policy titled Dishwashing, dated 2023, indicated Policy: All dishes will be properly sanitized through the dishwasher .8. A temperature log .will be kept and maintained by the dishwashers to assure the dish machine is working correctly . c. During an observation and interview on 12/17/24 at 2:37 PM of the emergency food supply, the Foodservice Director (FSD) stated there was several cases of over a thousand gallons of emergency water in blue cans that have a 20-year shelf life. The FSD further stated the cases of food items were enough for the 88 licensed beds, 37 assisted living residents, and 100 facility staff. The FSD stated the emergency food plan did not include visitors. The FSD and the Registered Dietitian (RD) both stated they had a 5-day regular menu for the cases of food, but they did not have a therapeutic menu for the therapeutic diets. The FSD stated the emergency plan binder was buried somewhere behind the cases of food in the storage closet. During an interview with the DON on 12/18/24 at 3:19 PM, the DON stated it was important for the facility to have an accurate emergency food menu plan for residents, facility staff, and visitors to use in the event of an emergency. A review of the facility's policy titled Emergency and Disaster Procedures dated 2023, indicated, Policy: Facilities will have a written plan of action which includes emergency menus to be used in the event of an emergency or disaster .Facilities will maintain an emergency food supply on the premises to last for a three-day period .11. Texture Modifications and Thickened Liquid Diet Orders, Residents with either prescribed texture and/or thickened liquid diet orders should be given the appropriate modifications .14. Emergency Menu and Spreadsheets .This menu is designed for a disaster .15. Emergency inventory will provide for the number of beds in the hospital as well as the staff and visitors . 3. Fortified Therapeutic Diets: 055435 Page 19 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of Facility Diet Order Tally Report-All Special Diets dated 12/16/24, indicated 21 residents were listed to receive a Fortified Diet (a diet designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status). During an observation of the lunch meal trayline service on 12/17/24 at 12:00 PM, the Dietary Aide (DA N) who assembled and checked the meal trays did not call out to the AFSD the residents on fortified diets. During an interview on 12/18/24 at 2:06 p.m., with the RD, the RD stated her expectation is the resident receives their physician-ordered therapeutic diet, which included Fortified diets. The RD also stated the facility's electronic health record program and the tray card software program perform monthly audits to ensure the tray cards match so residents are served the correct diets. The RD further stated it is important for the resident to receive the diet appropriate for their medical condition, and the kitchen staff should know how to serve the correct fortified foods during meal service. During an interview with the Director of Nursing (DON) on 12/18/24 at 3:19 PM, the DON stated the Licensed nurse (LN) will check the trays vs the tray card with the diet order and stated if they found a discrepancy, they are supposed to notify the kitchen. The DON further stated it was important to serve the correct physician-ordered diets to residents. A review of the facility's Diet manual dated 2024, indicated .Fortified Diet: is a regular diet that has added margarine, gravy, cheese, and mayonnaise. The diet adds 300-400 calories a day . A review of the facility policy titled Diet Orders dated 2023 indicated, Diet orders as physician as prescribed by the Physician will be provided by the Food & Nutrition Services Department. 055435 Page 20 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility did not ensure food and nutrition services staff performed their job tasks competently according to standards of practice and facility policy when: Residents Affected - Many 1. A Dietary Aide did not follow the recipe for puree salmon and a Diet Aide did not follow the recipe for tuna sandwiches. 2. A Dietary Aide did not properly test the sanitizing step of the high temperature dishwasher machine. 3. A Dietary Aide did not correctly demonstrate how to calibrate a food thermometer. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 84. Cross reference F800, 803 Findings: 1. a) During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K then added 2 scoops of thickener to salmon mixture and started mixing it. CK K stated did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. CK K then stated she would add more thickener if needed to make it thick. During an interview on 12/18/24 at 2:31 p.m., with the Registered Dietitian (RD), the RD stated the staff should be following the facility approved recipes and measurements for accurate calorie counts and nutrition, based on the instructions and spreadsheet. During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared.2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and the time and temperature guidelines . b) During a concurrent observation and interview on 12/16/24 at 3:31 p.m., with Dietary Aide M (DA M) was observed making tuna sandwiches for resident snacks. DA M stated she used 1 twelve ounce can of tuna from the dry storage room, chopped celery, and some mayonnaise to make the tuna salad. DA M stated she made it about an hour ago but did not check the temperature of tuna salad before she started making the sandwiches to ensure they reached 41 F before serving them. During an interview on 12/18/24 at 2:40 p.m., with the RD, the RD stated she expected the staff to know how make tuna sandwiches safely and to follow recipes. 055435 Page 21 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of recipe titled Tuna salad sandwich there is a direction indicated, .3. Suggest cut into four sections, cut to corner. Prior to serving, store sandwiches covered in the refrigerator. Keep chilled at less than 41 F until services. Serve in a pan on ice on tray line. During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance .7. Hold food prior to service for as short as time as practical. A maximum for 1-hour holding time is recommended. Hot foods should be held prior to service at 140 F or above and cold foods at 41 or below. Keeps food covered during holding . According to the Food and Drug Administration (FDA) Food Code 2022, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna P. 2. During a concurrent observation and interview on 12/16/24 at 10:01 a.m. with Dietary Aide L (DA L) and the Foodservice Director (FSD), DA L was asked to test the sanitizing step in the high temperature dishwasher machine. DA L stated I believe you have to check if the temperature is 180 degrees on the temperature gauge and that's all. The FSD acknowledged DA L did not know how to test the sanitizing process in the high temperature dish machine, then stated we use an Ecolab test strip on a dish rack that is run through the dish machine. The FSD told DA L to attach an Ecolab test strip to a dish and run it through the dishwashing machine. The test strip was gray then turned black after it went through the dishwash machine. The FSD stated the result was okay. Review of the Ecolab test strip indicated when indicator turns black, stated temperature has been achieved 160 degrees F/ 71 C. During an interview on 12/18/24 at 2:37 p.m., with the RD, she stated she expected the staff to know how to use the test strips to test the sanitizing step of the high temperature dish machine and record it on the log. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-204.113 Warewashing Machine, Data Plate Operating Specifications, indicated, .A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: (A) Temperatures required for washing, rinsing, and SANITIZING . During a review of facility's (P&P) dated, 2023 titled Dishwashing indicated, All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order .9. The dishwasher will run the dish machines until the temperature is within the manufacturer's recommendations . if you cannot achieve this temperature, alert the FNS Director or cook who will alert the Maintenance Department and stop washing dishes . High-temperature machine: if you do not have the manufacturer recommendations, use the machine at a temperature of 150 F to 165 F or higher for the wash and 180 F of or above for rinse. If you do not achieve the proper temperature, resort to the manual of dishwashing. 3. During a concurrent observation and interview on 12/17/24 at 11:07 a.m., with Dietary Aide N (DA N) and Assistant Foodservice Director (AFSD), DA N was asked to calibrate the thermometer used for the trayline. DA N filled a cup with ice, added water, then she placed the thermometer stem inside the cup with ice. The thermometer reading was 34 degrees F, then she removed the thermometer and stated the 34 F was correct. DA N further stated she did not get trained on how to calibrate a thermometer. AFSD acknowledged the thermometer was not at 32 degrees and stated, I know the temperature 055435 Page 22 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0802 Level of Harm - Minimal harm or potential for actual harm should reach 32 degrees, because I calibrated it this morning and it did. AFSD further stated he calibrates his thermometer about once a week but does not write it on a log. During an interview on 12/18/24 at 3:05 p.m., with the RD, the RD stated she expected the kitchen staff to know how to calibrate a thermometer and document it on a log. Residents Affected - Many According to the 2019 California Retail Food Code, section 113928 titled Temperature measuring device, TEMPERATURE MEASURING DEVICE means a thermometer, thermocouple, thermistor, or other device that indicates the temperature of FOOD, air, or water. 114159 (e) FOOD TEMPERATURE MEASURING DEVICEs shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. During a review of facility's (P&P) dated, 2023 titled Thermometer use and calibration indicated, Food thermometer are to be used properly and calibrated to ensure accurate temperature reading . Checking the Accuracy and Calibration .1 Fill a large glass with crushed ice and add a clean tap water until slush is formed. Stir the mixture well. 2. Put the thermometer's stem into the ice water to so that the sensing area is completely submerged (a dimple marks the end of the sensing area). Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must remain in the ice water one minute and during calibration process. 3. If the thermometer does not read 32 F, then the thermometer must be calibrated or discarded . 055435 Page 23 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews, and record review, the facility did not ensure standardized recipes for pureed meals and menus, which includes the emergency food supply were followed as printed, according to facility policy when: 1. A kitchen staff did not follow the facility's pureed diet lunch menu on 12/16/24 and 12/17/24. 2. A facility emergency menus unavailable These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status for 77 residents consuming food from the kitchen. Cross reference 800, 802 Findings: 1.a) During a review of the facility's Winter Menus, Week 3-Monday 12/16/24, the lunch meal pureed diet includes Fish Fillet with Tarragon Sauce, Tartar Sauce, Cajun Country Rice, Creamed Spinach, Parsley Sprig Garnish, Sweet Corn Salad, and Fruit Bavarian Cream. During an observation on 12/16/24 at 1:02 p.m., with Resident 56, Resident 56 was observed eating her lunch meal in front of St. Catherine's nurse's station. Resident 56 had no puree spinach on her plate. During a review of Resident 56's meal tray ticket, the tray ticket did not indicate a dislike for spinach or vegetables. During a concurrent interview and record review on 12/18/24 at 2:42 p.m. with the Registered Dietitian (RD), the RD stated she did not know the pureed spinach was not served to residents on the pureed diet. The RD stated she expected the kitchen staff to follow the menus for pureed diets, and all the other therapeutic diets. b) During a review of the facility's Winter Menus, Week 3-Tuesday 12/17/24, the lunch meal pureed diet includes Italian Lasagna, Seasoned Broccoli, Parsley Garnish, Garlic bread, peanut butter Cup Milk. During a test tray observation and interview on 12/17/24 at 12:48 p.m., with Foodservices Director (FSD) and RD, they confirmed residents on puree diet are getting puree wheat bread not a garlic bread from Menu dated 12/17/24. The FSD stated because it's hard to blend them [garlic bread]. During a concurrent interview and record review on 12/18/24 at 2:43 p.m., with the Registered Dietitian RD, the RD stated she expect the kitchen staff to follow the facility's menus for the residents to receive accurate calories and nutrition in order to meet their needs. During a review of facility's policy and procedure (P&P) dated, 2023 titled Menu Planning indicated, .3. All daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a logbook may be kept. Only the Facility Registered Dietitian, FNS Director or Cook, can make these changes. The FNS Director is to receive the Facility Registered Dietitian's 055435 Page 24 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some approval for any permanent changes. The Facility Registered Dietitian is to sign and date spreadsheets when changes are made.4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the Facility Registered Dietitian prior to the beginning of each quarterly menu cycle . 2.During a tour at emergency supply room observation and interview on 12/17/24 at 2:45 p.m., with the RD and the FSD, the written emergency binder with plan for water and food contained a 3-day regular menu for food. The emergency food binder did not include a menu for residents on therapeutic diets. The FSD stated the emergency plan included food for 88 licensed beds, 100 staff, but no visitors. The FSD further indicated there may be enough for 37 residents in Assisted living. The FSD stated the emergency binder was buried behind the cases of water and cases of disaster food items inside the small room near the employee break room. The RD and FSD both acknowledged it was important for the facility to have an accurate emergency menu with correct food and water amounts to meet the needs of the resident licensed beds, staff and visitors in the event of an emergency. During an interview on 12/18/24 at 2:46 p.m., the RD, the RD stated they followed up with a company for to obtain their emergency menu analysis portion and are still waiting for a response. During a review of facility's P&P dated, 2023 titled Emergency and Disaster Procedures indicated, Facilities will have a written plan of action which includes emergency menus to be used in the event of an emergency or disaster (e.g., fire, earthquake, explosion, flood, or strike). There may be disruption of the following: electricity, gas, water, or telephones. Facilities will maintain an emergency food supply on the premises to last for a three-day period . 4. Emergency Menu and Spreadsheets, Emergency and Disaster Procedures with completed Emergency Information form (refer to page 9.5), a can opener, and flashlight will be kept with the emergency food and paper supplies. Label area clearly with a sign, Emergency Food-Menus-Procedures (refer to next page or sign). This menu is designed for a disaster, which may disrupt gas, electricity, and water. All food may be served cold.15. Emergency inventory will provide for the number of beds in the hospital as well as the staff and visitors. The Administrator and FNS Director will agree on the number to provide for . 055435 Page 25 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the puree diet was followed as printed. Residents Affected - Some This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of twelve residents on puree diets. Cross reference F800 and F805 Findings: During a concurrent observation and interview on 12/16/24 at 9:45 a.m., a [NAME] K (CK K) was observed putting 5 scoops of bake salmon to blender machine, she added 2 cups of water using an aluminum measuring cup, then she blended it in a blender. After blending the pureed salmon, she acknowledged it was very watery. CK K then added 2 scoops of thickener to salmon mixture and started mixing it. CK K stated did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. CK K then stated she would add more thickener if needed to make it thick. During a review of recipe titled Pureed Meats there is a direction indicated, 1. Complete regular recipe. Measure out the number of portions for puree diets.2. Puree on low speed to a paste consistency before adding any liquid . During an interview on 12/18/24 at 2:31 p.m., with the Registered Dietitian (RD), the RD stated the staff should be following the facility approved recipes and measurements for accurate calorie counts and nutrition, based on the instructions and spreadsheet. During a review of the facility job description for .Cook . Revision date 9/01/16 indicated .Essential job functions: .Follow recipes and prepares foods that correspond to menu cycles and recipes prepared by Dietitian . During a review of facility's policy and procedure (P&P) dated, 2023 titled Food Preparation indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and the time and temperature guidelines . 055435 Page 26 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not ensure 21 residents receive their physician ordered therapeutic diet to meet their nutrition needs. This failure had the potential for to decrease nutrient intake and may have contribute to weight loss. Finding: According to a literature review of malnutrition, leading modifiable risk factors of malnutrition in Long-term care (LTC) include .poor nutrition .poor food/fluid intake .dependence on others for eating and impaired mobility. Additional .factors that lead to poor oral intake include poor food delivery systems . ([NAME], K.N.P., [NAME], S.R. & [NAME], C.W. Nutritional Vulnerability in Older Adults: A Continuum of Concerns. [NAME] Nutr Rep 4, 176-184 (2015). During a review of Facility Diet Order Tally Report-All Special Diets dated 12/16/24, indicated 21 residents were listed to receive a Fortified Diet (a Fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status). During a review of the facility's Diet manual dated 2024, indicated .Fortified Diet: is a regular diet that has added margarine, gravy, cheese, and mayonnaise. The diet adds 300-400 calories a day . During a lunch trayline meal service observation and interview on 12/17/24 at 12:00 p.m., Dietary Aide N (DA N) called out the regular or puree diets, and food dislikes listed on the meal tray tickets to Assistant Foodservice Director (AFSD), who placed the food on the plates. DA-N did not call out when a meal tray ticket had fortified on it. The Registered Dietitian (RD) acknowledged DA-N did not tell AFSD about the fortified diets listed on the tray tickets after the third meal cart went out. The RD then stated, DA-N should have called out the fortified diets to AFSD so they would have received the correct meal. The RD stated the fortified food item was to add a scoop of cheese to Italian lasagna entrée. During an interview on 12/18/24 at 2:06 p.m., with the RD, the RD stated her expectation is the resident receives their physician ordered therapeutic diet, which includes Fortified diets. The RD also stated the facility's electronic health record program and the tray card software program perform monthly audits to ensure the tray cards match so residents are served the correct diets. The RD further stated it is important for the resident to receive the diet appropriate for their medical condition, and the kitchen staff should know how to serve the correct fortified foods during meal service. During an interview on 12/18/24 at 3:19 p.m., with the Director of Nursing (DON), the DON stated the Licensed nurse (LN) will check the trays vs the tray card with the diet order and stated if they found a discrepancy, they are supposed to notify the kitchen. The DON further stated it was important to serve the correct physician-ordered diets to residents. During a review of the facility's policy and procedure (P&P) titled Tray Card System dated 2023 indicated, POLICY: Each meal tray at breakfast, lunch, and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies, beverage preference, and portion size. 055435 Page 27 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0808 During a review of the facility's P&P titled Diet Orders dated 2023 indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055435 Page 28 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. During observations, interviews, and record reviews, the facility did not ensure safe and sanitary practices were followed and maintained for food production and storage according to standards of practice and facility policy when: 1. An old dinner meal plate from the previous day was found inside the kitchen microwave the following day at 11:50 am. 2. Two dirty electric fans were inside the kitchen's food preparation and clean dish areas; 3. A cracked, dented, and worn aluminum measuring cup was used to make puree meals; These failures had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84. Cross reference F800, F802, F803 Findings: 1. During the initial kitchen tour observation on 12/16/24 at 9:30 a.m., a plate with a meat entrée resembling a pork chop, rice, broccoli, and a wheat dinner roll was found inside the microwave. During a follow up kitchen observation on 12/16/24 at 11:50 a.m., the meal plate was still inside the microwave. On 12/16/24 at 3:20 p.m., during an observation of the microwave, the microwave was empty and the meal plate was removed. During a review of the facility's Cook's Spreadsheet, Winter Menus, Week 3, Sunday 12/15/24 indicated .Regular IDDSI Level 7: Roast Pork Maple glazed sauce 1-2 tbsp., Baked potatoes, Broccoli with cheese sauce, wheat roll . During an interview on 12/18/24 with the Registered Dietitian (RD) at 2:29 p.m., the RD stated the meal found inside the microwave should not have been left inside the microwave overnight. The RD further stated the microwave should have been checked by the kitchen staff working on Sunday night and Monday morning so it would have been thrown out. 2. During the initial kitchen tour observation in the kitchen on 12/16/24 at 9:35 a.m., two Electric fans attached to the kitchen walls were observed was dusty with dark grey lint and black debris on the fan blades and covers. One fan was directly facing over the food preparation counter where kitchen staff were observed making snacks and sandwiches. During an interview on 12/18/24 at 1:54 p.m., with the Maintenance Director (MDR), the MDR stated cleaning the electric fans were not part of his maintenance duties. During an interview on 12/18/24 at 2:34 p.m., with the Registered Dietitian (RD), the RD stated the last time the fans were cleaned, it was by maintenance. The RD stated now the janitorial environmental services department cleans them, and they should have been cleaned. 055435 Page 29 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure titled Sanitation dated 2023 indicated, .8. The Maintenance Department will assist Food & Nutrition Services department as necessary in maintaining equipment and in doing janitorial duties which the Food & Nutrition Services employe cannot do and maintenance records on all equipment .1. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 3. During a concurrent observation and interview on 12/16/24 at 9:37 a.m., a [NAME] K (CK K) was observed making a puree salmon, she added 2 cups of water using a cracked, dented, worn out aluminum measuring cup, then she blended it in a blender. The number measurements were unreadable and scraped. CK K stated she did not know how much water or thickener she added because there weren't any measurement numbers on the cup and scoop she used. During an interview on /16/24 at 9:44 a.m., with the Foodservice Director (FSD), the FSD confirmed the aluminum measuring cup had a crack below the rim, dents around the cup, and unreadable number measurements. The FSD further stated they should have purchased new utensils for the Cooks to use. During an interview on 12/18/24 at 2:29 p.m., with the RD, the RD stated, the broken aluminum measuring cup is not acceptable and should be replaced. During a review of the facility's policy and procedure titled Sanitation dated 2023 indicated, The Food & Nutrition Services department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food .All equipment shall be maintained as necessary and kept in working order .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 055435 Page 30 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented when: Residents Affected - Few 1. Staff failed to ensure the dirty linen container was fully covered by having dirty linen sticking out of the container; 2. Staff failed to ensure a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea [a condition where breathing repeatedly stops and starts during sleep]) mask and hose were properly disinfected; 3. Staff failed to label two urinals found in a shared resident bathroom with resident identifier; 4. During a treatment, a registered nurse (RN) grabbed multiple items with gloved hands without changing the gloves, 5. One licensed vocational nurse(LVN) did not disinfect the glucometer in between blood sugar level checks. These failures had the potential to compromise residents' health and safety in the facility. Findings: 1. During an observation and concurrent interview with Certified Nurse Assistant (CNA) G on 12/16/24 at 11:25 a.m., there was one soiled linen bin in the hallway. The bin was not covered, and the soiled linens were exposed and overflowing. CNA G stated the soiled linen bin should be covered and should not be overflowing. During an observation and concurrent interview with CNA I on 12/16/24 at 11:33 a.m., CNA I confirmed the bin was full and overflowing. CNA, I stated it should not be full and overflowing. During a concurrent interview and record review with the Director of Nursing (DON) on 12/19/24 at 4:04 p.m., the DON confirmed the soiled linen bin should be covered and should not be overflowing, as this could put the facility at risk for the spread of infection. During a review of the facility 's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, revised September 2022, the P&P indicated, Soiled laundry bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Transport 1. Contaminated linen and laundry bags container are not held close to the body or squeezed during transport. 2. Review of Resident 84's clinical record indicated Resident 84 was admitted on [DATE] and had diagnoses of obstructive sleep apnea and asthma (a condition in which the airways narrow and swell). Review of Resident 84's physician order, dated 12/9/24, indicated to apply CPAP machine pressure 10-15 at bedtime for obstructive sleep apnea and remove per schedule. During a concurrent observation and interview on 12/16/24 at 9:58 a.m., inside the room of Resident 055435 Page 31 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0880 Level of Harm - Minimal harm or potential for actual harm 84, the CPAP mask was on top of the bedside table exposed and it was not in plastic bag. Resident 84 stated the staff leave the mask exposed after removing it. During a concurrent observation and interview with Certified Nurse Assistant (CNA) J on 12/16 /24 at 12:46 p.m., CNA J confirmed the mask was not in a plastic bag. Residents Affected - Few During an interview with the Director of Nursing (DON) on 12/19/24 at 4:08 p.m., the DON confirmed the above observation and stated the mask should be cleaned and placed in a plastic bag after. During a review of the facility's policy and procedure titled, CPAP/BIPAP Support, revised dated March 2015, indicated, General guidelines for cleaning 7. Masks, nasal pillow, and tubing: Clean daily by placing in warm, soapy water Rinse with warm water and allow it to air dry between uses. 3. During an observation on 12/16/24 at 12:47 p.m., in Resident room [ROOM NUMBER], two urinals were noted to be sitting above the toilet on a shelf. The urinals did not have any resident identifiers on them. During an interview with CNA A on 12/17/24 at 2:30 p.m., CNA A said for residents who use shared bathrooms, all items in the bathroom should be labeled with the resident's name. During an interview with the DON on 12/19/24 at 11:30 a.m., the DON said items in a shared bathroom should have the resident's name on them. 4. During an observation on 12/19/24 at 6:51 a.m., RN B was observed grabbing a privacy curtain more than once and a paper towel more than once. RN B was also observed not changing gloves after those instances, but changed gloves after dropping a cup filled with normal saline soaked gauze. During an interview with the DON on 12/19/24 at 11:30 a.m., the DON said one should not used gloved hands to grab items that are not for treatment, and that staff should do hand hygiene if they need to change gloves. A review of facility policy and procedure titled Handwashing/Hand Hygiene, last revised August 2019, indicated Use an alcohol-based hand rub containing at least 62% alcohol [ .] After contact with objects in the immediate vicinity of the resident; After removing gloves [ .] 5. During a medication administration observation on 12/17/24 at 4:14 p.m., Licensed Vocational Nurse (LVN) D was observed removing the [brand name of] glucometer from the drawer of the medication cart and cleaned the glucometer and medication tray with alcohol wipes before she obtained the blood sugar reading for Resident 11. When finished, she cleaned the glucometer and medication tray with alcohol swabs and placed it back in the drawer of the medication cart. During an interview on 12/17/24 at 4:30 p.m., LVN D stated that alcohol, or the [brand name of] (a germicidal disinfectant) could be used to clean equipment, but the Sani-Cloth took three minutes to dry. She stated she preferred to use alcohol swabs because it was quicker to disinfect equipment if she had a lot of residents to care for. She stated, I have three residents on this side. During the medication administration observation on 12/17/24 at 4:37 p.m., LVN D cleaned the glucometer and medication tray with alcohol swabs after she obtained the blood sugar reading for Resident 20, then returned the glucometer to the drawer of the medication cart. 055435 Page 32 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/17/24 at 4:55 p.m. with the Director of nursing (DON) and the Director of Staff Development (DSD), the DSD stated, The nurses should always use the [brand name of] wipes to clean the glucometer. She also stated, The staff received the instruction during the in-service conducted on 12/16/24. A review of the facility's P&P (policy and procedures) titled, Obtaining a Fingerstick Glucose Level, dated October 2011 indicated, Clean and disinfect reusable equipment between uses according to manufacturer's instructions and current infection control standards of practice. A review of the manufacturer's instructions titled, [brand name of glucometer], System of Monitoring of Blood Glucose, indicated, Cleaning and disinfecting can be completed using a commercially available EPA [environmental protection agency] -registered disinfectant detergent or germicide wipe. 055435 Page 33 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not ensure a coffee machine was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. Residents Affected - Few This failure had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84. Cross reference F800 Findings: During an observation of the lunch trayline meal service on 12/16/24 and 12/17/24, the Diet Aide N (DA N) was observed preparing coffee for the resident meals using the coffee machine. DA N prepared 78 cups of coffee on 12/16/24 and 77 cups of coffee on 12/17/24 during each of the lunch meal services. During a concurrent observation and interview on 12/17/24 at 9:50 a.m., with the Foodservices Director (FSD), the FSD confirmed the coffee machine had three missing buttons, electrical wires exposed inside each button space, and a clear strip of tape securing the coffee machine's door. The FSD stated the coffee machine had these issues for several months but the facility was on a wait list to get a different coffee machine from the coffee vendor soon. During an interview on 12/18/24 at 2:54 p.m., with the Registered Dietitian (RD), the RD stated, the broken buttons of the coffee machine were on Quality Assurance and Performance Improvement Plan (QAPI- a data-driven approach to improving the quality of care in nursing homes) since 10/28/24. The RD stated they are on the waitlist for a new coffee machine because the buttons don't work and it's a safety issue for kitchen staff. During a review of the facility policy titled Sanitation dated 2023 indicated, The Food & Nutrition Services department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food .All equipment shall be maintained as necessary and kept in working order .11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 055435 Page 34 of 35 055435 12/20/2024 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to ensure that resident rooms (Rooms 150, 151, 152, 153, 156, 160, and 163) measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility. Findings: The room measurements indicated seven resident rooms were less than 80 square feet per resident. Room Number of Beds Square feet/Resident 150 2 71.5 151 2 71.5 152 2 78 153 2 78 156 2 71.5 160 2 78 163 2 71.5 During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The staff and the residents moved freely in the rooms. The residents and the staff stated the square footage of the rooms was not a concern. Continuance of the room waiver is recommended. 055435 Page 35 of 35