VILLAS AT SARATOGA SKILLED NURSING & ASST LVG, THE

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 received the care, supervision, and services needed to meet R1's toileting needs when staff S1 assisted R1 to the bathroom, which poses an immediate personal rights and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a plan of correction by 01/10/2026 stating how the licensee will conduct in-service training with staff to ensure that resident receive the care, supervision, and services that meet their individual needs, including resident's toileting needs. Once training is completed, the licensee shall submit copies of training records, including names of staff trained, dates of training, training topics, and names and qualifications of trainers.

Deadline recorded: Jan 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of 7 resident Centrally Stored Medication and Destruction Records (CSMDR), 1 out of 7 CSMDRs was missing two medications, which poses a potential health risk to residents in care.

Official plan of correction

POC Due Date: 09/25/2025 Plan of Correction Licensee agrees to conduct an audit of all residents centrally stored medication and destruction records by plan of correction date of 09/25/2025 and submit a statement of completion by the same date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of 7 staff records, 5 out of the 7 staff records did not have a health screening form, which poses a potential safety risk to residents in care.

Official plan of correction

POC Due Date: 09/25/2025 Plan of Correction Licensee agrees to submit copies of health screening forms for staff S1-S5 by Plan of Correction Due Date of 09/25/2025.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement This requirement was not met as evidenced by: Based on review of 7 staff records, 1 out of 7 staff records did not include a current first aid certification, which poses a potential health risk to residents in care.

Official plan of correction

POC Due Date: 09/25/2025 Plan of Correction Licensee agrees to submit an updated first aid certification for staff S5 by Plan of Correction Due Date of 09/25/2025.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Licensee did not ensure that R1's bottle of medication M1 was kept in a safe and locked place, which poses an immediate safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a Plan of Correction by POC date stating how the licensee will ensure that resident medications are kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medication.

Deadline recorded: Apr 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review and observation the licensee did not ensure resident R2, R4, and R5’s centrally stored medications records were complete by missing information such as medications, start dates, and refills which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2023 Plan of Correction Licensee conducted an in-service training on medications on 10/04/2023 with staff. Licensee began correcting residents CSMRs to include their start dates and refill information. Licensee will submit to LPA the facility's policies and procedures regarding medication labeling which will be obtained from the pharmacy to LPA Dolores by POC due date.