The Villas at Saratoga Skilled Nsg & Assisted Lvg

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment when one resident (Resident 1) out of five sampled residents did not receive adequate supervision when Resident 1 was able to leave the facility alone unattended on 4/7/26. This failure resulted in Resident 1 becoming intoxicated due to alcohol consumption while outside the facility and put Resident 1 at risk for physical injury, dehydration, and psychosocial distress. Upon return to the facility, Resident 1 was sent via 911 (emergency services) to acute hospital for evaluation. During an interview on 4/8/26 at 11:03 a.m. with the Director of Nursing (DON), the DON stated Resident 1 left the faciity on 4/7/26 and returned at around 10 p.m. intoxicated (being drunk or under the influence of drugs, where alcohol or substances impair a person's physical and mental abilities). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure to notify local police, ombudsman (independent official, who advocates residents), and state agency in a timely manner following an allegation of abuse reported by facility's staff member for one out of two sampled resident (Resident 1). This failure had the potential for further abuse and delay implementation of appropriate corrective actions for sampled Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to maintain standard infection prevention and control practices to prevent the spread of infections when: 1. Unlabeled wash basins left on floor in resident's bathroom and in sink;2. Clean and used equipment storage areas were not separated in oxygen (O2, colorless, odorless, and tasteless gas essential for life) supplies storage room;3. House Keeping staff did not perform hand hygiene after removed gloves. These failures had the potential for all currently residing 84 residents in facility at increased risk of healthcare- associated infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure to develop and implement a person-centered care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, preferences and values) for speech therapy (ST, a specialized healthcare service that diagnoses and treat communication, language, cognitive, and swallowing disorders for residents) for one of 3 sampled resident (Resident 1). This failure had the potential to result in not meeting Resident 1's plan of care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide safe environment to prevent the risk for accident hazard in one of 3 sample resident room (room [ROOM NUMBER]) and in oxygen (O2, colorless, odorless, and tasteless gas essential for life) supplies storage room when: [...]

Inspectors wroteBased on interview and record review, the facility failed to offer pneumonia (PNA, an infection in one or both lungs [a pair of spongy organs in the chest that serve as the main components for breathing], that can cause mild to serious illness) vaccine (substance that making body stronger against specific harmful germs) timely for one of five sampled resident (Resident 2). This failure had the potential to negatively affect Resident 2's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure to administer pain medication as needed when nursing staff noted with signs and symptoms (S/S including moaning, groaning, restlessness, agitation, crying, facial grimacing and guarding the affected area) of pain for one of three sampled resident (Resident 1) to meet professional standards of care. This failure had the potential to affect Resident 1's pain management, health condition and well-being.

Inspectors wroteBased on interview and record review, 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). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide resident's room free from sound for one of three sampled resident (Resident 1). This failure had the potential to affect Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications (chemicals or compounds used to cure, halt, or prevent diseases or illnesses) left unattended in resident's room for one of three sampled resident (Resident 1)'s room. This failure had the potential for residents to have an unsafe access to medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received adequate supervision to prevent an elopement for one of three sampled residents (Resident 1) when Resident 1 eloped and found on the street after being monitored by the nursing staff. This failure placed residents at risk for further elopement.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff interviews, and document reviews, the facility failed to ensure overall dietetic services systems for food safety and sanitation were met, according to standards of practice and facility policy. This failure exposed the residents to contaminants (potentially harmful substances) in foods and unsanitary practices, which could have further compromised their nutritional status. The facility census was 84. Cross reference F802, F803, F804, F808, F812, and F908

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food and nutrition services staff performed their job tasks competently according to standards of practice and facility policy when: 1. A Dietary Aide did not follow the recipe for puree salmon and a Diet Aide did not follow the recipe for tuna sandwiches. 2. A Dietary Aide did not properly test the sanitizing step of the high temperature dishwasher machine. 3. A Dietary Aide did not correctly demonstrate how to calibrate a food thermometer. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 84.

Inspectors wroteDuring observations, interviews, and record reviews, the facility did not ensure safe and sanitary practices were followed and maintained for food production and storage according to standards of practice and facility policy when: 1. An old dinner meal plate from the previous day was found inside the kitchen microwave the following day at 11:50 am. 2. Two dirty electric fans were inside the kitchen's food preparation and clean dish areas; 3. A cracked, dented, and worn aluminum measuring cup was used to make puree meals; These failures had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three of 4 residents (Residents 16, 62 and 84) had been informed about having an advance directive (AD, legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about AD and the Physician Orders for Life -Sustaining Treatment (POLST, a legal document stating the kinds of medical treatments patients want toward the end of their lives) was not completed and readily available in the event of a medical emergency. This failure had the potential to result in the inability to make medical decisions, and could lead to the delivery of unnecessary or inappropriate medical services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their bed rail (adjustable rigid bars attached to the side of a bed) policy for 12 of 18 sampled residents (Residents 2, 4, 8, 16, 20, 23, 33, 43, 51, 67, 70 and 82). The facility failed to follow their bed rail policy for use of grab bars when: 1. For Resident #2 there was no physician order for the use of grab bars; 2. For Resident #43 and Resident 67 there was no physician order for the use of grab bars; 3. For Residents # 23, 33, 8, and 82, there were no care plans for the use of grab bars; 4. For Resident # 70, there was no physician order or care plan for the use of grab bars; 5. For Resident # 4, and 20 there was no physician order or care plan for the use of grab bars; 6. For Resident # 4, 16, 20, and 51 there were no care plans for the use of grab bars; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure standardized recipes for pureed meals and menus, which includes the emergency food supply were followed as printed, according to facility policy when: 1. A kitchen staff did not follow the facility's pureed diet lunch menu on 12/16/24 and 12/17/24. 2. A facility emergency menus unavailable These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status for 77 residents consuming food from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the puree diet was followed as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of twelve residents on puree diets.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure 21 residents receive their physician ordered therapeutic diet to meet their nutrition needs. This failure had the potential for to decrease nutrient intake and may have contribute to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat three of 18 sampled residents (Residents 25, 45, and 64) with respect and dignity when: 1. The certified nurse assistant (CNA) stood beside the residents to assist with their meals, and 2. Resident 25's urine bag (bag that is attached to a tube that is connected to the bladder) was not covered. These failures resulted in not ensuring residents were treated with respect and dignity, and could potentially affect the residents' self-worth. Findings 1. During a dining observation on 12/16/24 at 12:37 a.m., the CNA G assisted Resident 45 with her meal. The CNA G was standing while trying to feed Resident 45. At 12:40 a.m., the CNA G assisted Resident 64 with her meal. The CNA G was standing while feeding Resident 64. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of 18 sampled residents (Resident 20) to address the use of Clopidogrel (medication used to prevent blood clots). This failure had the potential to compromise the facility's ability to implement interventions to maintain the resident's well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care according to facility policy and procedure for one of 24 sampled residents (Resident 70) when a registered nurse (RN B) did not have the running of the continuous tube feeding (nutrition that is given through a tube that goes directly into the stomach) placed on hold when they put Resident 70's head of the bed flat to carry out a pressure ulcer treatment. This failure had the potential for enteral feeding complications that could cause harm to this resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (procedure to remove waste and excess fluid from the body) communication reports were complete (NDCRs) for one of 18 sampled residents (Resident 62). This failure had the potential to put Resident 62 at risk for complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate accountability of controlled drugs (those with high potential for abuse and addiction), when there were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 3 out of 6 residents (Residents 33, 9 and 28). This failure had the potential for abuse or misuse of controlled drugs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days for one of six sampled residents (Resident 2). This failure had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8.82% when three medication errors occurred out of 34 opportunities during the medication administration for two of four residents (Residents 18 and 89). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications or adverse effects, compromising their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Staff failed to ensure the dirty linen container was fully covered by having dirty linen sticking out of the container; 2. Staff failed to ensure a continuous positive airway pressure machine (CPAP, machine used to treat sleep apnea [a condition where breathing repeatedly stops and starts during sleep]) mask and hose were properly disinfected; 3. Staff failed to label two urinals found in a shared resident bathroom with resident identifier; 4. During a treatment, a registered nurse (RN) grabbed multiple items with gloved hands without changing the gloves, 5. One licensed vocational nurse(LVN) did not disinfect the glucometer in between blood sugar level checks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a coffee machine was maintained in a safe operable condition according to manufacturer's guidelines and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve coffee in a safe and sanitary manner. Facility census was 84.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide free of accident hazard during transfer for one of three residents (Resident 1) when the facility failed to complete a fall risk evaluation for Resident 1 upon admission, Certified nursing assistant A (CNA A) did not follow the Hoyer (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) lift's user instruction manual when CNA A did not check the sling which suitable for the particular resident, the correct size, and CNA A did not follow the policy and procedure about using a mechanical lifting machine to gently support the resident as she moved. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. Food storage containers were wet, and with white stains in kitchen storage cabinets; 2. Utensil storage drawer had brown dried particles; 3. Food blender black gasket with brown dried particles; 4. [NAME] cutting board with stained and scratches; 5. Tip of can opener blade with small black substance; and 6. Ice scooper was placed close to a soap dispenser. These failures had the potential to result in food borne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility did not implement COVID-19 (a highly contagious respiratory disease) screening protocol; 2. Staff did not perform hand hygiene in between tasks; 3. Clean linen room had debris, dust, loose off-white particles and black matter stuck to the floor; 4. Soiled linen bin with dirty linens in it was left opened in the hallway; 5. Resident's used surgical mask was left hanging on a wheelchair handle; 6. A used mask was left on the screening table; 7. The treatment nurse (TN) did not perform hand hygiene in between task; and 8. Staff did not wear gloves in handling soiled linen. These failures could result in the spread of infection and cross-contamination that could affect the 86 residents who resides in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and respect was provided for one of three residents (Resident 6) when staff did not assist Resident 6 during lunch while other residents at the same table were already eating. This deficient practice violated the resident's right to be treated with dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess if the resident was safe to self-administer medications for one of 20 sampled residents (Resident 49). This failure had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure time change was communicated to one of 18 resident (Resident 52) when Resident 52 was not aware the day light saving time (DST) ended. This failure had the potential to result in resident needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 18 residents (Residents 32, 138, and 139) were made aware of an advance directive. This failure had the potential of leaving residents not having a way for their health care wishes to be followed, by a selected representative, if they become incapacitated.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or their representative in writing and the office of the long-term care ombudsman (ombudsman) for two of three residents (Residents 32 and 76) when transferred to a general acute care hospital (GACH). This failure had the potential of residents being transferred wrongfully.

Inspectors wroteBased on interview and record review, the facility failed to notify two of three residents (Residents 32 and 76) or their representatives of the facility's bed hold policy when they were transferred to a general acute care hospital (GACH). This failure had the potential of residents not being allowed to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS, a resident's clinical assessment) Significant Change in Status Assessment (SCSA - a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 21 residents after Resident 88 had a worsened pressure ulcer and a significant weight loss (weight loss of five percent or more in the last month, or ten percent or more in the last six months). This failure had the potential to negatively affect the planning of care and provision of appropriate services for this resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for one of 18 residents (Resident 50). This failure had the potential for mentally ill residents not to receive the required care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensue services provided meet professional standards for two of 20 sampled residents (Resident 14 and 48) when: 1. One nursing staff did not follow the physician's order for administering as needed Morphine (a controlled medication for moderate to severe pain) 2. One nursing staff did not use two identifiers to identify a resident prior medication administration. These failures had the potential for medication administration error (given a wrong dose) and administer a medication to a wrong resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure necessary care and grooming services were provided for two of two residents (Resident 15 and Resident 18) when Residents 15 and 18's fingernails were long, had yellow and black particles, and were not trimmed. This failure had the potential to affect the residents' care and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Resident 6 and 50) received the necessary care, and services when: 1. Resident 6's wound assessment was not done; and 2. Resident 50's care plan intervention for the use of thrombo-embolic deterrent (TED, specialized stockings to help prevent leg swelling and blood clots) hose was not implemented. These failures had the potential to affect the resident's care, health, and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to prevent pressure injury for one of three residents (Resident 51) when white cream was applied to Resident 51's coccyx (tail bone) area not consistent to the physician order. This failure had the potential to cause of worsen pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of five sampled residents, (Resident 24, 64 and 2) were free from unnecessary psychotropic medications (medication capable of affecting the mind, emotions and behavior) when: 1. For Resident 24, failed to identify and monitor the specific target behavior for the use of quetiapine fumarate (Seroquel, medication use to treat certain mental/mood conditions such as schizophrenia [severe mental disorder affecting how a person's think, feel and behaves]) 2. For Resident 64, the facility failed to ensure there was a specific duration of use for PRN (PRN, as needed) psychotropic medication that exceed 14 days for the use of Lorazepam (medication for anxiety [persistent feeling of worry and fears]); 3. For Resident 2, the facility failed to monitor a specific behavior for the use of Seroquel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when an insulin (medication to treat high blood sugar) pen had the pharmacy label on the cap instead of the body of the pen. This deficient practice had a potential to result in medication errors due to medications not being labeled and stored appropriately.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician prescribed thickened liquid for one out of one sampled resident (Resident 51). This failure put Resident 51 at risk for aspiration (food or liquid going into the lungs) that could compromise his health condition, and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two garbage disposal dumpster container lid was closed. This failure had the potential for harborage and feeding of pests.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 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. [...]

Inspectors wroteBased 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 frustration and had the potential to impact both residents' abilities to communicate their needs and delay treatment.

Inspectors wroteBased 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.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.