Health inspection·August 12, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few Page 1 of 3 055435 055435 08/12/2025 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 meet professional standards of care when staff did not intervene for a resident who was known to feed a roommate with swallowing problems (Residents 1 and 2). For Resident 3 she was not adequately monitored to prevent elopement and there was no policy addressing wander guard (alarm device such as a wrist band that sound when a person exits) maintenance and function for two of four sampled residents (Residents 1, 2 and 3). These failures placed residents at health and safety risk.Findings:1. Review of Resident 2's face sheet (document summarizing a resident's essential medical information) indicated she had diagnoses including dysphagia (difficulty swallowing food or liquid) and dementia (group of thinking and social symptoms that interferes with daily function). Her Minimum Data Set (MDS, an assessment tool, dated 4/18/25, indicated Resident 2 had severe problems with daily decision-making skills.Resident 2 had a physician's order, dated 6/5/25, indicating specific feeding instructions to provide close supervision, assist with cutting items, palpate (touch) resident while giving solids to ensure initiation of swallow, provide verbal cues as needed, slow rate, small bolus (amount) and ensure resident is awake and alert.During an interview on 7/30/25 at 12 noon, the speech language pathologist (SLP, healthcare professional who diagnoses and treats people with communication and swallow disorders) stated Resident 2 required one on one supervision to eat safely, needed to be alert during meals and was at medium risk for aspiration (inhalation of food or liquid into the lungs).Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 3/27/25, indicated the resident had moderate difficulty with daily decision-making skills.During an interview on 7/2/25 at 6:20 p.m., the CNA A stated he witnessed Resident 1 trying to feed her roommate (Resident 2) a lot and also gave Resident 2 fluids.During an interview on 7/3/25 at 12:14 p.m., CNA F stated Resident 1 fed Resident 2 about two to three times a week since they became roommates and did not report it to the charge nurse.Review of Resident 1's record indicated there was no care plan developed addressing Resident 1's behavior of feeding other residents until requested on 7/2/25.During an interview on 7/3/25 at 12:10 p.m., LVN C stated she had heard about Resident 1 feeding Resident 2 once or twice and did not do anything.During an interview on 7/3/25 at 12:58 p.m., LVN D stated she heard Resident 1 fed and applied lotion to her roommate and she informed the social worker to have residents change rooms.Review of Resident 1's Census list form indicated the resident resided in Room A from 4/26/25 to 6/20/25.Review of Resident 2's Census list form indicated the resident resided in Room A from 4/28/25 to 7/1/25.During an interview on 7/30/25 at 10:35 a.m., the director of nurses (DON) stated residents were not allowed to feed other residents and there should have been a room change between the two residents and the room change did not occur and there was no policy addressing who could feed residents.Review of Resident 2's hospital Discharge summary, dated [DATE] at 9:03 p.m., indicated the resident was being treated with a diagnosis including aspiration pneumonia (type of lung infection caused by inhaling something other than air into the lungs).2. Review of Resident 3's face sheet indicated the resident had diagnoses including dementia. Resident 3's MDS, dated [DATE], indicated the resident had severe problems with daily decision-making skills.During an interview on 7/2/25 at 11 a.m. licensed vocational nurse (LVN) C stated Resident 3 was confused, always walking around the facility, looking for exits, and she wandered into other resident rooms about once every shift (8 hours).During an interview on 7/3/25 at 1:30 p.m., LVN D stated Resident 3 was very confused especially in the afternoon after 4 p.m. and she wandered into other resident's rooms.Review of Resident 3's Nurse's Note, dated 3/16/25 at 8:05 a.m., indicated the resident was brought back to her room three times, she was peeking into other resident's rooms, and she had suddenly Residents Affected - Few 055435 Page 2 of 3 055435 08/12/2025 The Villas at Saratoga Skilled Nsg & Assisted Lvg 20400 Saratoga-Los Gatos Rd Saratoga, CA 95070

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 conditionDuring 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. 055435 Page 3 of 3