Health inspection·December 23, 2025

The Villas at Saratoga Skilled Nursing Provider#055435 EID-1D934D-H1 Exit 11/25/25 F689 Title 42 Code of Federal Regulations §483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 Code of California Regulations §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to ensure to provide moderate assistance (helper does less than half the effort) for bed mobility, transfer, ambulation, maximum assistance (helper does more than half the effort) for toileting hygiene (process of using commode for urination and bowel movement), and failed to document comprehensive risk for fall care plan with person centered interventions for staff's assistance for bed mobility, transfer, ambulation, toileting and hygiene to prevent a fall for one of three sampled resident (Resident 2). Above these failures were resulted in an unwitnessed fall with right femur neck (part of the largest, and strongest thigh bone that connects the ball shaped head of the femur to the rest of the bone, critical structural component of the hip joint) fracture (broken bone) and underwent surgery (a medical procedure, often involving cutting into the body) to fix the fracture for Resident 2. Findings: Review of Resident 2's face sheet (a document that gives resident's information at a quick glance) indicated Resident 2 was admitted to facility on 8/25/2025. Resident 2's admission diagnoses included diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), open wound (a break or injury in the skin) to right foot, lack of coordination (a condition that affects the body's ability to control and execute smooth and precise movements), muscle weakness (a condition where muscles lose their strength), congestive heart failure (a chronic condition where heart muscles weakened, difficult for the heart to pump blood effectively throughout the body), peripheral vascular disease (a condition that affects blood vessels, typically in the legs), and depression (a serious mental condition with persistent feelings of sadness, hopelessness, and loss of interest in daily activities). Review of Resident 2's minimum data set (MDS: clinical and functional assessment tool) assessment dated 9/1/2025, section C for brief interview for mental status (BIMS) indicated, score of 4/15 (score of 0-7: severely impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition), severely impaired cognition. Review of Resident 2's MDS assessment dated 9/1/2025 for functional limitation in range of motion (ROM: full movement capability of a joint or series of joints) assessment indicated, impairments on both sides of lower extremities (legs), required moderate assistance for lying to sitting on side of bed, sit to stand, chair to bed-to chair transfer, toilet transfer, and walk 10 feet, and maximum assistance for toileting hygiene needs. Review of Resident 2's history and physical notes dated 8/25/2025, documented by Resident 2's primary care physician (PCP: a healthcare professional who serves as point of contact for general medical needs and routine check-ups) indicated, "does not have capacity to make medical decisions. Reason-cognitive impairment." Review of Resident 2's morse fall scale (a common healthcare tool used to quickly assess a resident's risk for fall) assessment dated 8/25/2025, indicated, moderate risk for fall. Review of Resident 2's bowel and bladder program screener, dated 8/25/2025, indicated, continent of bowel and bladder with 1 person assistance with get to bathroom, transfer to toilet/commode/urinal, and adjust clothing and cleaning. Review of Resident 2's physical therapy (PT: a healthcare specialty that focuses on restoring, maintaining, and improving physical function) notes dated from 8/26/2025 to 9/24/2025, musculoskeletal system assessment indicated, impaired left lower extremity strength, hip, knee and ankle. Functional mobility assessment indicated, Resident 2 needed moderate assistance with transfers and ambulation. This notes also indicated, Resident 2 required fall risk precautions. Review of Resident 2's occupational therapy (OT: a healthcare profession that aims to improve ability to participate in activities of daily living [ADL]) notes dated from 8/26/2025 to 9/24/2025, indicated, poor standing balance, impaired safety awareness, impaired short-term memory (information only held for a brief period, generally 15 5o 30 seconds before it begins to fade away) and risk for fall. This notes was also indicated Resident 2 needed moderate assistance with toileting, transfer to commode, and personal hygiene. Review of Resident 2's speech therapy (ST: a healthcare profession that focuses on improving and restoring cognitive communication) notes, dated from 8/26/2025 to 9/24/2025, indicated, Resident 2 was oriented to person only and impaired insight (awareness of a problem or situation). Review of Resident 2's change of condition (COC: a significant change from baseline health, function or mental status, that requires interventions to address) dated 10/2/2025, indicated, around 10 p.m., nursing staff heard a thud (sound that made when something heavy falls or hits something else) and found Resident 2 lying on floor next to left side of his bed, unwitnessed fall. Review of Resident 2's nursing post fall evaluation notes dated 10/2/2025, indicated, fall was occurred in the Resident 2's room and fall was not witnessed. This notes was also indicated Resident 2 was attempting to use toilet by himself at the time of the fall. Review of Resident 2's COC dated 10/3/2025 indicated Resident 2 complained of right thigh pain during repositioning and was observed slight bluish-green discoloration, swelling, and right leg size longer than left leg. MD ordered an x-ray (an exam to create pictures of inside the body) to right leg. Review of Resident 2's right hip x-ray results, dated 10/4/2025, indicated, "Age-indeterminate femoral neck fracture of the right femur. Presumed acute fracture." Review of Resident 2's nurse's notes, dated 10/4/2025, indicated, Resident 2 was sent out to acute hospital (AH: a medical facility that provides short-term and intensive care with severe or urgent health conditions) for further evaluation. Review of Resident 2's AH medical doctor's documentation, dated 10/6/2025, indicated, Resident 2 was fell at a nursing facility and sustained a displaced right femoral neck fracture. This documentation also was indicated Resident 2 underwent hemiarthroplasty (a type of partial hip replacement surgery to treat hip fracture) to right hip on 10/6/2025 and discharged back to facility on 10/9/2025. Review of Resident 2's comprehensive care plan for at risk for falls with or without injury, date initiated on 8/25/2025, indicated, there was no documented evidence of person centered interventions for staff to provide moderate assistance for bed mobility, transfer, ambulation, toileting, and maximum assistance for personal hygiene for Resident 2. During an interview with certified nursing assistant B (CNA B) on 10/22/2025 at 11:38 a.m., CNA B stated Resident 2 alert to name only, risk for fall, and depends on one staff's physical assistance with transfers, bed mobility, toileting and personal hygiene since Resident 2's admission to facility. CNA B also stated Resident 2 unable to ambulate self without one staff's assistance for safety to prevent a fall. During an interview with license vocational nurse A (LVN A) on 10/22/2025 at 12:10 p.m., LVN A stated Resident 2 required one staff's physical assistant with his transfers, bed mobility, ambulation, toileting and hygiene. During an interview with MDS coordinator C (MDSC C) on 10/23/2025 at 12:50 p.m., MDSC C stated based on MDS assessment, dated 9/1/2025, Resident 2 needed one person physical assistance with bed mobility, transfers, ambulation and bathroom use. MDSC C also stated based on nursing documentation at the time of the fall on 10/2/2025 indicated, there were no staff present to provide moderate assistance for Resident 2 to prevent the fall with fracture. MDSC further stated there was no nursing documentation indicated Resident 2 placed call light or not and called for assistance or not before the fall happened on 10/2/2025. During a concurrent review of Resident 2's PT, OT and ST notes dated from 8/26/2025 to 9/24/2025 and interview with occupational therapist (OT: a healthcare specialist who helps residents to improve ability to engage in activities of daily living) on 10/23/2025 at 1:24 p.m., OT reviewed above notes, confirmed Resident 2 was required moderate assistance from staff for transfers, ambulation, toileting, and maximum assistance for personal hygiene. OT stated Resident 2 was required one staff's physical assistance to complete above tasks. OT also stated Resident 2 was risk for fall and had poor safety awareness. OT further stated if staff were provided moderate assistance as Resident 2 needed, fall with injury could be avoided for Resident 2 on 10/2/2025. During an interview with facility's director of nursing (DON) on 10/23/2025 at 3:02 p.m., DON confirmed Resident 2 was high risk for fall since admission and was required fall precautions to prevent fall with or without injury. DON also confirmed Resident 2 required for staff to provide moderate assistance with activities of daily living. DON further confirmed no staff were present to provide physical assistance to Resident 2 to prevent the fracture after the fall on 10/2/2025 with his bed mobility or transfer, or ambulation, or toileting or hygiene needs. DON stated based on nursing documentation at the time of the fall indicated, no documented evidence for Resident 2 called for staff's help or not, before the fall happened. DON stated fall with fracture could be prevented if staff were provided assistance as needed for Resident 2 to use bathroom that day. During a concurrent review of Resident 2's care plan for risk for plan, date initiated 8/25/2025 and interview with MDSC D on 11/12/2025 at 12:47 pm., MDSC D reviewed above care plan and confirmed there were no documented evidence of person centered interventions for staff to provide moderate assistance for bed mobility, transfer, ambulation, toileting and maximum assistance for personal hygiene based on Resident 2's MDS assessment dated 9/1/2025. MDSC D stated this care plan should have documented evidence of person centered interventions to provide required moderate to maximum assistance for above tasks to prevent fall with or without injury for Resident 2. During an interview with facility's DON on 11/12/2025 at 1:04 pm., DON stated MDS staff were responsible for person centered care plans based on MDS assessment and ADL needs for each resident. DON also stated MDS staff should have reviewed, updated, and documented risk for fall care plan with person centered interventions to provide required assistance to prevent falls for Resident 2. Review of facility's policy and procedure (P&P) titled, "Activities of Daily Living (ADL), Supporting," revised March 2018, the P&P indicated, "Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish ... Appropriate care and services will be provided to residents who are unable to carry out ADLs independently including appropriate support and assistance with: b. Mobility (transfer and ambulation, including walking): c. Elimination (toileting)." Review of facility's P&P titled, "Falls and Fall Risk, Managing," revised March 2018, the P&P indicated, "The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Review of facility's P&P titled, "Care Plans, Comprehensive Person-Centered," revised March 2022, the P&P indicated, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT: a group of professionals from different backgrounds who collaborate to provide person-centered care to residents), in conjunction with resident and his/her family or legal representative develops and implements a comprehensive, person-centered care plan for each resident." The facility failed to ensure to provide moderate assistance (helper does less than half the effort) for bed mobility, transfer, ambulation, maximum assistance (helper does more than half the effort) for toileting hygiene (process of using commode for urination and bowel movement), and failed to document comprehensive risk for fall care plan with person centered interventions for staff's assistance for bed mobility, transfer, ambulation, toileting and hygiene to prevent a fall for one of three sampled resident (Resident 2). These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.