Other·January 29, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 1/17/2020. The facility was licensed for 85 beds. The census at the time of the survey was 81. The sample size was 18. A Class "B" citation was also issued (see

F759). Representing the California Department of Public Health: 32892, Health Facilities Evaluator Supervisor; 38087, Health Facilities Evaluator Supervisor; 39949, Health Facilities Evaluator Nurse; 42437, Health Facilities Evaluator Nurse.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 02/15/2020 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 1 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of 18 sampled residents (Residents 41 and 59) and in two of two hallways. This failure resulted in the residents' discomfort and had the potential for all residents to be uncomfortable in the hallways. Findings: 1. During a concurrent observation and interview on 1/14/2020 at 2:45 p.m., Certified Nursing Assistant (CNA) A was at Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 2 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 59's bedside, and Resident 59 stated she was cold. During a concurrent observation and interview on 1/15/2020 at 2:10 p.m. with the Director of Maintenance (DOM), in Nursing Station (NS) A, the DOM was observed using the temperature gun to check the temperature in Resident 59's room. The temperature gun readings indicated a range of 69 to 81 degrees Fahrenheit. During a concurrent observation and interview on 1/16/2020 at 1:33 p.m. with the DOM, in NS A and NS B, the DOM was observed using the temperature gun to check the hallway temperatures and the readings were 69 degrees Fahrenheit in each hallway. During a concurrent interview and record review on 1/16/2020 at 1:33 p.m. with the DOM, the "Maintenance Request" sheets in the NS A binder, dated 12/20/2019, 12/19/2019, and 12/18/2019, were reviewed. The "Maintenance Request" sheets did not indicate a heating problem. The DOM stated the 12/20/2019 "Maintenance Request" sheet is the most recent for the NS A. There was no communication regarding the cold room temperature in NS A from 1/14/2020. During an interview on 1/16/2020 at 1:55 p.m. with the Director of Nursing (DON), she stated the CNA A should have communicated that Resident 59 felt cold on 1/14/2020 to the licensed nurse and with maintenance via the request log. During a review of the facility's policy and procedure, "Work Orders, Maintenance," dated April 2010, the policy indicated "It shall be the responsibility of any individual employee with knowledge of a needed work order to fill out the work order information in the binder." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 3 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Scratches on the back of the door. During an observation and interview on 1/13/2020 at 3:48 p.m., Resident 41 pointed towards the back of her door. The back of the door was observed with peeling paint from scratches. Resident 41 stated, "I feel awful to see the wall like that, I would never have this if this was in my own house." Resident 41 also stated that she already reported it to the administrator. During an interview on 1/13/2020 at 4:25 p.m. with the administrator (ADMIN), the ADMIN confirmed he was aware of the scratches on Resident 41's door. The ADMIN stated it will be a big project and it would take a while for them to fix it.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 02/15/2020 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to administer medications as prescribed for two of seven sampled residents (Residents 59 and 134) when: 1. For Resident 59, the licensed nurse did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 4 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administer the prescribed PRN (as needed) cough medicine when the resident was coughing. 2. For Resident 134, the licensed nurse did not administer the prescribed PRN pain medications for the pain levels indicated on the physician's orders. This failure had the potential to cause discomfort and delay treatment for the residents. 1. During an observation and interview on 1/14/2020 at 2:45 p.m., Resident 59 was observed, in bed, with a wet cough (a type of cough that results from the mucus in the airways). Resident 59 stated she wasn't getting medicine for the cough. During a record review of Resident 59's "Physicians Orders," dated 1/3/2020, the orders indicated to administer Geri-Tussin Syrup (guaifenesin) (cough medicine used to reduce chest congestion by breaking up mucus so it can be coughed out) to be given every four hours PRN for cough. During a record review of Resident 59's "Medication Administration Record," dated Jan 2020, the record indicated Geri-Tussin Syrup (guaifenesin) was administered on 1/14/2020 at 2:29 a.m., and the next dose was given on 1/15/2020 at 8:39 a.m. The medication was not given during the daytime on 1/14/2020. During a concurrent interview and record review on 1/15/2020 at 11:18 a.m. with Licensed Vocational Nurse (LVN) D, he stated on 1/14/2020, Resident 59 was coughing during the daytime and he did not give the PRN cough medicine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 5 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/16/2020 at 1:55 p.m., with the Director of Nursing (DON), she stated the nurse should have given the PRN cough medication, knowing Resident 59 had a cough throughout the day. During a review of the facility's policy and procedure, "Medication Administration General Guidelines," dated 09/18, the policy indicated "Medications are administered in accordance with written orders of the prescriber." 2. During a record review of Resident 134's "Order Summary Report," dated 01/17/2020, the report indicated to give HydrocodoneAcetaminophen (an opioid pain medication) 5325 mg (milligram, a unit of measure) every 4 hours as needed for moderate pain and Hydromorphone HCl (an opioid pain medication) every 4 hours as needed for severe pain. During a review of the facility's policy and procedure, "Administering Pain Medications," dated October 2010, the policy indicated the "Wong-Baker FACES Pain Rating Scale" (a standardized pain assessment tool) as the assessment tool used for pain. The tool was attached to the policy and indicated pain ratings of four, five, and six as "moderate pain" and pain ratings of seven, eight, and nine as "severe pain" During a concurrent interview and record review on 1/17/2020 at 12:40 p.m. with the DON, Resident 134's "Medication Administration Record [MAR]," dated Jan 2020, was reviewed. The record indicated the Hydrocodone-Acetaminophen Tablet 5-325 mg, prescribed for moderate pain, was given for pain levels of seven, eight, and nine (severe pain) on 35 occasions between 1/2/2020 and 1/14/2020. The record also indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 6 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Hydromorphone HCl, prescribed for severe pain, was given for pain levels of five and six (moderate pain) on three occasions between 1/5/2020 and 1/12/2020. The DON confirmed the pain levels on the MAR are consistent with the pain assessment tool in their policy. During a review of the facility's policy and procedure, "Administering Pain Medications," dated October 2010, the policy and procedure indicated that a pain assessment should be conducted prior to giving pain medication and that pain medication should be administered as prescribed. During a review of the facility's policy and procedure, "Medication Administration General Guidelines," dated 09/18, the policy indicated "Medications are administered in accordance with written orders of the prescriber."

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 02/15/2020 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 7 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide communication tools and services for two out of three residents (10 and 26) with communication barriers when: 1. For Resident 10, the facility staff were unable to establish communication and did not implement the use of a communication board (A communication tool that includes words, phrases, and/or pictures in a foreign language and English used to facilitate communication for people with language barriers) as indicated in the care plan. 2. For Resident 26, the facility did not ensure that communication can always be established through a translator, as indicated in the care plan, or other tool, in the absence of a translator. These failures resulted in Resident 10's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 8 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE frustration and had the potential to impact both residents' abilities to communicate their needs and delay treatment. Findings: 1. During a review of Resident 10's "Physician's Progress Note," dated 6/15/19, the note indicated "Unable to talk to patient. No translator available ...Please call our office to R/S [reschedule]." During a record review of Resident 10's "OBRA Annual Assessment," dated 10/23/2019, the assessment indicated the resident needs or wants an interpreter to communicate. During observations on 1/13/2020 at 10:48 a.m., and 1/15/2020 at 9:28 a.m., Resident 10 was observed in her room speaking in a nonEnglish language to Certified Nursing Assistant (CNA) A and CNA B. Both CNA A and CNA B left the room to locate the Occupational Therapist (OT) to translate. During another observation and concurrent interview on 1/16/2020 at 10:10 a.m., CNA C was observed trying to establish communication with Resident 10. CNA C did not find a communication board at the bedside. Resident 10's eyes widened, and she continued to speak in a non-English language with a louder tone and faster pace. CNA C stated she would find Licensed Vocational Nurse (LVN) D, the OT, or call the son to translate. Resident 10 used her cell phone, stated "call son," dialed a number, and shook her head. LVN D did not speak Resident 10's non-English language and the OT was not on duty. During a record review of Resident 10's "Admission Record," dated 1/16/2020, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 9 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record indicated the primary language was non-English and the need for assistance with personal care. During a concurrent interview and record review on 1/16/2020 at 11:32 a.m. with the Social Services Director (SSD), Resident 10's "Social Services Care Plan," dated 01/04/2020, was reviewed. The SSD stated the CNA and licensed nurses should utilize the communication board. During a review of the facility's policy and procedure, "Communication" (undated), the policy stated, "The facility will provide effective communication between residents and staff as identified ...staff will periodically check to ensure that resident continues to have tools readily available." 2. During a review of Resident 26's "Admission Record," dated 1/16/2020, the record indicated the primary language was non-English and the need for assistance with personal care. During a concurrent observation and interview on 1/16/2020 at 8:29 a.m. with Resident 26, in her room, Resident 26 used gestures, shook her head and pointed to communicate. During a concurrent interview and record review on 1/16/2020 at 11:32 a.m. with the SSD, Resident 26's "Social Services Care Plan," dated 10/04/2019, indicated "Resident requires translator with communication." For Resident 26, the SSD stated LVN D can translate five days a week and family visits often. There is no translator during all hours of the day. During an interview on 1/16/2020 at 1:55 p.m. with the Director of Nursing (DON), the DON stated a communication board should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 10 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE available and accessible to everyone for residents with a language barrier and is especially important when a translator is not available. During a review of the facility's policy and procedure, "Communication" (undated), the policy stated, "The facility will provide effective communication between residents and staff as identified ...staff will periodically check to ensure that resident continues to have tools readily available."

F684 SS=D Quality of Care CFR(s): 483.25

F684 02/15/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one out of 18 Residents (44) received care and services by failing to provide medication as prescribed. This failure put Resident 44's health and safety at risk. Findings: During a review of Resident 44's Admission Record, dated 1/16/2020, the Admission Record indicated Resident 44 was originally admitted on 11/26/2018 and readmitted on 12/20/19 with diagnoses of anemia, gastroesophageal reflux disease (GERD, occurs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 11 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when stomach acid frequently flows back into the tube (esophagus) connecting mouth and stomach), nonrheumatic aortic valve stenosis (narrowing of the heart's valve), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness ) and acute on chronic diastolic (congestive) heart failure (is a condition when the heart is not able to fill properly with blood, reducing the amount of blood pumped in the body). During a review of Resident 44's General Acute Care's Discharge - Patient Medication List, dated 11/18/19, the Discharge - Patient Medication List indicated a physician order for Pantoprazole (Protonix, used to decrease the amount of acid produced in the stomach) 40 mg (milligram, a unit of measurement) oral daily at 0900 last dose was given on 11/18/19 at 6:30 a.m. During a review of Resident 44's Progress Notes, dated 12/11/19 at 8:55 a.m., the progress notes indicated Resident 44 was transferred to general acute care hospital related to chest pain and critically low lab result. During a review of Resident 44's General Acute Care's Discharge Summary, dated 12/20/19, the discharge summary indicated Resident 44 was admitted on 12/11/19 with the following discharge diagnoses including anemia secondary to acute blood loss anemia, acute gastrointestinal bleed secondary to esophagitis, acute on chronic respiratory failure (is a condition in which not enough oxygen passes from your lungs into your blood) and chronic renal failure stage three to four kidney disease (gradual loss of kidney function). During a review of Resident 44' Minimum Data FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 12 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Set Assessment (MDS, a comprehensive assessment), dated 11/25/19, indicated on Section C (Cognitive Patterns) Resident 44 BIMS (Brief Interview for Mental Status) Summary Score was 15. During a review of Resident Assessment Instrument 3.0 User's Manual, dated 10/2019, indicated BIMS Summary Score of 15 indicated Resident 44 was cognitively intact. During an interview on 1/15/2020 at 12:00 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that there was no documentation that Resident 44 received Protonix from 11/19/19 to 12/11/19. The ADON also confirmed there was an order for Protonix on 11/18/19 that was not added on Resident 44 electronic health records. During an interview on 1/15/2020 at 2:02 p.m. with Resident 44, Resident 44 stated she did not recall receiving Protonix every morning before her hospitalization on 12/11/2019. During an interview on 1/15/2020 at 2:43 p.m. with Resident 44's Medical Doctor (MD), the MD stated Resident 44' s hospitalization could have been prevented if Resident 44 was given Protonix. During an interview on 1/15/2020 at 3:46 pm., the ADON stated Resident 44's physician's order for Protonix was not added on the medication administration record (MAR) on 11/18/19 and there was no documentation from the admission nurse that Protonix was discontinued found. During an interview and record review on 1/16/2020 at 3:39 p.m. with the Director of Nursing (DON), the DON stated Resident 44 was on Protonix 40 mg since 1/16/18 for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 13 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE GERD. During an interview on 1/17/2020 at 8:37 a.m. with the DON, the DON confirmed the admission nurse forgot to add the pantoprazole in Resident 44's electronic health records and the reason why the medication was not being given. The DON also stated Protonix could have prevented gastritis. During an interview on 1/17/2020 at 9:12 a.m. with the consultant pharmacist (CP), the CP stated Protonix decreases the gastric content that could prevent gastritis. During an interview and record review on 1/17/2020 at 11:09 a.m. with the DON, the DON stated there was no documentation on Resident 44's health records that medication was reconciled during admission. During a review of the facility's policy and procedure, "Medication Administration General Guidelines", dated 9/10, indicated medications are administered in accordance with written orders of the prescriber. During a review of the facility's policy and procedure, "Reconciliation of Medications on Admission", dated 7/2017, indicated medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosage and routes, during the admission/transfer process.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 02/15/2020 §483.45 Pharmacy Services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 14 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview record reviews the facility failed to follow pharmacy services policies and procedure when: 1. For Resident 188, new medication orders were not delivered on a timely manner. 2. For Residents 134 and Resident 31, the facility failed to ensure accurate or effective accountability of controlled substances (drugs with high potential for abuse or addiction). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 15 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Nurse's station one had two of the same emergency kits. These failures caused delayed in treatment and potential to put resident's health and safety at risk. Findings: 1. For Resident 188, new medication orders were not delivered on a timely manner. During an interview on 1/13/2020 at 10:30 a.m., Resident 188's family member stated Resident 188 was admitted on 1/12/2020 but the facility nurses were still not able to administer morning medications. During an interview on 1/13/2020 at 10:33 a.m. with licensed vocational nurse A (LVN A), LVN A confirmed that four medications were still not delivered from the pharmacy for Resident 188. During an interview on 1/14/2020 at 12:12 p.m. with the director of nursing (DON), the DON stated new medications for Resident 188 were faxed to the pharmacy the night before and should be delivered by the pharmacy on a timely manner. During an interview on 1/17/2020 at 10:39 p.m. with the pharmacy director (PD), the PD stated the medication for Resident 188 should be delivered to the facility prior to nine a.m. medication administration. During a review of the facility's policy, dated 9/10, "Ordering and Receiving Non-Controlled Medication", indicated medications and related products are received from the provider pharmacy on a timely basis and timely delivery of new orders is required so that medication administration is not delayed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 16 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. For Residents 134 and 31, the facility failed to ensure accurate or effective accountability of controlled substances (drugs with high potential for abuse or addiction). During a review of Resident 134's Controlled Drug Record, indicated Hydromorphone (a controlled substance two used for pain) 2 mg tablet give half tab by mouth every four hours as needed: a. On 1/5/2020 at 11:00 a.m., two half tabs (#82 and #81) were signed out of the controlled drug record but there was no documentation on the MAR (medication administration record). b. On 1/5/2020 at 11:59 p.m., one half tab (#80) was signed out of the controlled drug record but there was no documentation on the MAR. During an interview on 1/17/2020 at 9:08 a.m. with the director of nursing (DON), the DON confirmed above findings. The DON also stated that there were no nurses progress notes related to medication above. During a review of Resident 31's Controlled Drug Record, indicated Hydromorphone 2 mg tablet give half tab by mouth every three hours as needed for moderate to severe pain: a. On 12/4/19 at 9:35 a.m., two half tabs (#46 and #45) were signed out of the controlled drug record but facility nurses only documented one half tab on the MAR was given to Resident 31. b. On 12/25/19 at 1:00 a.m., one half tab (#37) was signed out of the controlled drug record but there was no documentation on the MAR. c. On 1/6/2020 at 6:45 p.m., two half tabs (#17 and #16) were signed out of the controlled drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 17 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record but facility nurses only documented one half tab on the MAR was given to Resident 31. During an interview on 1/17/2020 at 9:08 a.m. with the director of nursing (DON), the DON confirmed above findings. The DON also stated that there were no nurses progress notes related to medication above. During a review of the facility's policy, "Medication Administration General Guidelines", dated 9/10, indicated the resident's MAR/TAR (treatment administration record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. During a review of the facility's policy, "Controlled Substances", dated 12/12, indicated the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. 4. Nurse's station one has two of the same emergency kits. During an observation and interview with the Assistant Director of Nursing (ADON) on 1/14/2020 at 3:04 p.m., injectable emergency kit #1073 and injectable emergency kit #1174 was found inside a nursing station. The ADON stated that both emergency kits were the same medications and the facility should only have one per nursing station. During an interview with the pharmacy director (PD) on 1/17/2020 at 10:42 a.m., the PD stated the facility should only have one injectable emergency kit per nursing station. The PD also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 18 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated when new injectable emergency kits arrived, nursing staff should exchange old emergency kit. During a review of the facility's policy, dated 9/10, "Emergency Pharmacy Service and Emergency Kits", indicated when the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 02/15/2020 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 19 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure one of 18 sampled residents (4) were free from unnecessary psychotropic drugs (any drug that affects brain activity) when psychiatry recommendations were not acted on timely manner. This deficient practice had the potential to put residents at risk to receive unnecessary psychotropic medications. Findings: During a review of Resident 4's admission records, dated 1/16/2020, indicated Resident 4 was admitted on 4/8/2019, started hospice care on 4/11/19, with diagnoses of malignant neoplasm (cancerous tumor) of pancreas and prostate, psychosis (a mental disorder in which thought and emotions are so impaired that contact is lost with external reality), dementia FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 20 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (problems with memory and thinking) and high blood pressure. During a review of Resident 4's physician's order, dated 8/20/19, indicated Seroquel (an anti-psychotic medication used to treat certain mood and mental conditions) 100 mg (milligram, a unit of measurement) twice a day for psychosis lability manifested by physical aggression. During a review of Resident 4's physician's order, dated 11/30/19, indicated Depakote (used for seizures and bipolar disorder) 250 mg extended release for mood lability manifested by unprovoked angry outburst. During a review of Resident 4's psychotropic quarterly review, dated 11/22/19, indicated Resident 4 has zero episodes of physical aggression on October 2019. During a review of Resident 4's psychiatry assessment, dated 12/20/2019, indicated the resident was stable in current medications and recommends routine lab work for Depakote monitoring - liver enzymes and valproic acid. Psychiatry assessment also indicated to consider gradual dose reduction on Seroquel to 75 mg twice a day and monitor for relapse of prior behaviors. During an interview with the social service director (SSD) on 1/16/2020 at 11:41 a.m., the SSD stated it takes some time for psychiatry assessment to be received by the facility. Psychiatry assessment that was done on 12/20/19 was not received by the facility until 1/14/2020. During a review of the facility's policy, dated 1/2020, "Tapering Medication and Gradual Dose Reduction", indicated if outside provider FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 21 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE is being consulted regarding gradual dose reduction, social services or designee will follow up and/or request with outside provider regarding any documentation(s) in a timely manner.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 02/15/2020 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent (%), as evidenced by the identification of eight medication errors out of 29 opportunities, to yield a facility medication error rate of 27.59%: 1. For Resident 188, four medications were not given. 2. For Resident 67, the physician's order was not followed. 3. For Resident 26, three medication dosages were not fully given as prescribed. These failures had the potential to compromise the residents' medical health and safety. Findings: 1. For Resident 188, four medications were not given. During a review of Resident 188's Admission Records dated 1/17/2020, indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 22 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 188 was admitted on 1/12/2020 with diagnoses of epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), hypertension (high blood pressure) and presence of cardiac pacemaker (a medical device that generates electrical impulses delivered by electrodes to cause the heart muscle to pump blood). During a medication administration observation with licensed vocational nurse A (LVN A) on 1/13/2020 at 10:33 a.m., LVN A administered Resident 188 Sodium Chloride (supplement) one gram (GM, a unit of measurement). During an interview and record review with LVN A on 1/13/2020 at 10:38 a.m., LVN A stated Amlodipine 10 mg (milligram, a unit of measurement) for hypertension, Atorvastatin 20 mg for hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), Vimpat 100 mg for partial seizures (a sudden, uncontrolled electrical disturbance in the brain) and Metoprolol 25 mg for hypertension were not administered because they are not available from the pharmacy. During an interview on 1/13/2020 at 10:44 a.m. with the Director of Nursing (DON), the DON stated Resident 188's medication should be administered on a timely manner as prescribed by the physician. During a review of the facility's policy and procedure, "Medication Administration General Guidelines", dated 9/10, indicated medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only be persons legally authorized to do so. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 23 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. For Resident 67, the physician's order was not followed. During a review of Resident 67's Admission Records dated 1/17/2020, indicated Resident 67 was admitted on 8/20/19 with the following diagnoses including vascular dementia (memory loss), type two diabetes (a condition in which the body has high sugar levels for prolonged periods of time) and hypertension. During an observation on 1/13/2020 at 1:00 p.m., with licensed vocational nurse B (LVN B), LVN B administered bolus feeding to Resident 67. During an observation on 1/13/2020 at 1:12 p.m. with LVN B, LVN B administered five units of Humalog to Resident 67. During an interview and record review on 1/13/2020 at 1:14 p.m., LVN B stated the physician order indicated to give five units of Humalog prior to bolus feeding. During an interview on 1/14/2020 at 12:02 p.m. with the DON, the DON stated nurses should follow the physician's order for Resident 67 to administer Humalog first prior bolus feeding. During a review of the facility's policy and procedure, "Medication Administration General Guidelines", dated 9/10, indicated medications are administered in accordance with written orders of the prescriber. 3. For Resident 26, three medication dosages were not fully given as prescribed. During a review of Resident 26's Admission Records dated 1/16/2020, indicated Resident 26 was admitted on 8/28/18 with following diagnoses including atrial fibrillation, anemia (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 24 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE condition in which the body lack enough healthy red blood cells to carry adequate oxygen), dementia and hypertension. During an observation on 1/13/2020 at 4:52 p.m. with licensed vocational nurse C (LVN C), LVN C crushed Resident 26's Carvedilol 6.25 mg, Cranberry one tab and Seroquel 75 mg separately and mixed with apple sauce. LVN C was observed not fully administering the medication dosage because there were still left over in each cup. During an interview on 1/13/2020 at 5:04 p.m., LVN C stated he did not fully administer three dosages of Resident 26's medications because there were still residuals on each cup. During a review of Resident 26's Order Summary Report, dated 1/16/2020, Order Summary Report indicated a physician's order for Carvedilol tablet 6.25 mg give one tablet by mouth two times a day related to essential hypertension, hold for SBP (systolic blood pressure is the peak blood pressure during heart contraction) less than 100, Cranberry juice extract give one tablet by mouth two times a day for UTI (urinary tract infection) prophylaxis and Seroquel give 75 mg by mouth tow times a day for psychosis/delusions manifested by persistent screaming related to other psychotic (disconnection from reality) disorder. During an interview on 1/14/2020 at 12:06 p.m. with the DON, the DON stated nurses should administered the full dose of the medication for Resident 26 as prescribed. During a review of the facility's policy and procedure, "Medication Administration General Guidelines", dated 9/10, indicated medications are administered as prescribed in accordance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 25 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with manufacturer's specifications, good nursing principles and practices and only be persons legally authorized to do so.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/15/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to follow policy and procedure related to medication storage when: 1. Three out of four nursing station refrigerators FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 26 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were not being monitored accordingly when storing vaccines. 2. Expired Medications 3. Two licensed nurses left medication unattended. These deficient practices put resident's health and safety at risk. Findings: 1. Three out of four nursing station refrigerators were not being monitored accordingly when storing vaccines. During an observation at station one's medication refrigerator with the assistant director of nursing (ADON) on 1/14/2020 at 3:04 p.m., the ADON confirmed Afluria (flu vaccine) was stored inside the refrigerator while the facility staff was only monitoring temperature once a day. During an observation at station two's medication refrigerator with the ADON on 1/14/2020 at 3:25 p.m., the ADON confirmed two Afluria and one Prevnar (vaccine used to prevent infection caused by pneumococcal bacteria) was stored inside the refrigerator while the facility staff was only monitoring temperature once a day. During an observation at station four's medication refrigerator with the ADON on 1/14/2020 at 3:35 p.m., the ADON confirmed two Prevnar and one Fluzone (flu vaccine) was stored inside the refrigerator while the facility staff was only monitoring temperature once a day. During a review and interview with the director of staff development (DSD) of Center's for Disease Control and Prevention website on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 27 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/15/2020 at 9:10 a.m., the DSD stated Vaccine Storage and Handling indicated, temperature monitoring of the storage unit at least two times each workday. 2. Expired Medications During an observation at station three's medication refrigerator with the ADON on 1/14/2020 at 3:29 p.m., the ADON confirmed a vial of tuberculin (used in a test by hypodermic injection for infection with or immunity to tuberculosis) was opened on 12/1/19. The ADON stated that tuberculin was only good 30 days after opening. During a review of manufacturer's guideline for tuberculin, indicated vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 3. Two licensed nurses left medication unattended. During an observation on 1/13/2020 at 1:04 p.m., licensed vocational nurse B (LVN B) left Duoneb (a medication to prevent wheezing and shortness of breath) on top of Resident 67's bed side and walked towards nurse's station. During an observation on 1/13/2020 at 1:11 p.m., LVN B left 5 units of Humalog (used to regulate sugar in the blood) on top of Resident 67's bed side and walk outside the room to check the orders on the computer. During an interview on 1/13/2020 at 1:14 p.m., LVN B stated he was not allowed to leave medications unattended. During multiple observations with licensed vocational nurse C (LVN C) on 1/13/2020 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 28 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4:38 p.m., and 4:39 p.m., LVN C left a bottle of eye drops and a tablet of sodium chloride (a supplement) unattended. During an interview on 1/13/2020 at 4:50 p.m., LVN C confirmed he left medication unattended in two separate occasions. During an interview on 1/14/2020 at 12:02 p.m. with the director of nursing (DON), the DON stated medication should not be left unattended. During a review of the facility's policy, "Medication Administration General Guidelines", dated 9/10, indicated during medication administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medication when unlocked.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 02/15/2020 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 29 of 30 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055435 (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAS AT SARATOGA SKILLED NURSING AND ASSISTED LIVING 20400 Saratoga Los Gatos Rd Saratoga, CA 95070 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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 None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 67CM11 Facility ID: CA070000007 If continuation sheet 30 of 30