Inspection Reports for
The Villas at Saratoga Skilled Nursing & Asst Lvg
20400 SARATOGA LOS GATOS RD, SARATOGA, CA, 95070
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
238% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in pain management at the nursing facility.
Findings
The facility failed to administer pain medication as needed to Resident 1 after a fall despite signs and symptoms of pain, potentially affecting the resident's pain management and well-being.
Deficiencies (1)
F 0658: The facility failed to administer acetaminophen as ordered for pain management when Resident 1 exhibited signs and symptoms of pain after a fall on 8/31/2025.
Report Facts
Medication dosage: 325
Date of fall: Aug 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Confirmed failure to administer pain medication as ordered |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 25, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of The Villas at Saratoga Skilled Nursing and Assisted Living facility to assess compliance with regulatory requirements related to resident care, safety, and medication management.
Findings
The facility was found deficient in providing a quiet environment for residents due to noise from metal plates near Resident 1's room, failure to provide adequate assistance and a comprehensive fall risk care plan for Resident 2 which resulted in a fall with a femur fracture, and failure to ensure medications were securely stored and not left unattended in Resident 1's room.
Deficiencies (3)
F 0584: The facility failed to provide a resident's room free from noise due to metal plates on the driveway making sounds when stepped on or when cars passed, affecting Resident 1's quiet time.
F 0689: The facility failed to provide moderate to maximum assistance and a comprehensive fall risk care plan for Resident 2, resulting in an unwitnessed fall with a right femur neck fracture requiring surgery.
F 0761: The facility failed to ensure medications were stored in locked compartments and left medications unattended in Resident 1's room, posing a potential safety risk.
Report Facts
Medication capsules and tablets observed: 11
Medication liquid volume: 10
Resident 1 BIMS score: 5
Resident 2 BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | LVN | Confirmed medications left unattended in Resident 1's room and described medication preparation |
| Director of Nursing | DON | Confirmed Resident 2 was high risk for falls and lack of staff assistance at time of fall; confirmed medications should not be left unattended |
| Certified Nursing Assistant B | CNA | Reported Resident 2 required assistance with transfers and hygiene |
| MDS Coordinator C | MDSC | Reported Resident 2 needed assistance and no staff present at time of fall |
| Occupational Therapist | OT | Confirmed Resident 2 required moderate to maximum assistance and was at risk for falls |
| Consultant Pharmacist | CP | Confirmed medications should be stored locked and not left unattended |
| Maintenance Supervisor | MS | Confirmed metal plates near Resident 1's room made noise due to loose fitting |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident at the facility.
Complaint Details
The complaint investigation found that Resident 1 eloped from the assisted living second floor, was missing for over 15 minutes, and was found with injuries outside the facility. The resident had severe cognitive impairment and was not monitored hourly prior to the incident. The facility's elopement policy lacked guidance on prevention.
Findings
The facility failed to ensure adequate supervision to prevent elopement of a resident with severe cognitive impairment, resulting in the resident being found outside with injuries. The facility lacked sufficient alarms on exit doors and did not implement hourly monitoring until after the elopement occurred.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in a resident elopement and injury.
Report Facts
Duration resident missing: 15
Response time to alarm: 285
Number of exits outside facility: 11
Number of unalarmed assisted living exits: 5
Date of resident's Minimum Data Set: Aug 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses | Reviewed records and stated resident was not placed on hourly monitoring until after elopement. |
| Maintenance Director | Maintenance Director | Reviewed facility cameras and confirmed lack of alarms on exit doors. |
| Assistant Director of Nurses | Assistant Director of Nurses | Stated exit doors for confused residents were not safe and staff should have monitored residents to prevent elopement. |
| Assisted Living Supervisor | Assisted Living Supervisor | Responded to alarm in 4 minutes 45 seconds during observation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely suspend certified nurse assistants accused of resident mistreatment and failure to provide appropriate treatment and care according to orders, including inadequate monitoring and lack of policies for feeding and elopement prevention.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident mistreatment by CNAs and failures in care related to feeding and elopement prevention. The findings substantiated minimal harm with few residents affected.
Findings
The facility failed to suspend two CNAs accused of resident mistreatment, placing residents at risk. Additionally, the facility did not meet professional care standards by allowing a resident to feed another with swallowing problems, failing to monitor a resident at risk for elopement, and lacking policies for wander guard maintenance and feeding supervision.
Deficiencies (2)
F 0607: The facility failed to timely suspend two certified nurse assistants accused of resident mistreatment, risking further harm to residents.
F 0684: The facility failed to provide appropriate treatment and care by not intervening when a resident fed a roommate with swallowing problems and by inadequately monitoring a resident at risk for elopement without proper policies for wander guard maintenance.
Report Facts
Residents Affected: 2
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) B | Did not suspend CNA A after learning about allegations | |
| Licensed Vocational Nurse (LVN) C | Changed CNA B's assignment but did not suspend after abuse allegation; also involved in interviews regarding feeding and elopement issues | |
| Director of Staff Development (DSD) | Stated policy requires immediate leave for accused staff | |
| Speech Language Pathologist (SLP) | Provided assessment of Resident 2's feeding needs | |
| Certified Nurse Assistant (CNA) A | Accused of verbally disrespecting Resident 1 and feeding Resident 2 | |
| Certified Nurse Assistant (CNA) F | Reported Resident 1 fed Resident 2 multiple times | |
| Licensed Vocational Nurse (LVN) D | Heard about feeding incidents and informed social worker | |
| Director of Nurses (DON) | Stated residents were not allowed to feed others and care plans were missing | |
| Maintenance Director (MD) | Reported lack of alarms on exits and elevator related to elopement risk | |
| Environmental Service Director (EVS) | Participated in tour noting exit alarm deficiencies | |
| Medical Record Director (MRD) | Reviewed records and noted missing elopement care plan |
Inspection Report
Routine
Deficiencies: 17
Date: Dec 20, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare facility regulations including resident rights, care planning, medication management, dietary services, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity, incomplete advance directive documentation, lack of care plans for medications and bed rail use, medication administration errors, dietary service deficiencies including unsafe food handling and inaccurate diet provision, infection control lapses, and equipment maintenance issues.
Deficiencies (17)
F 0550: The facility failed to treat three residents with respect and dignity by having staff stand while assisting with meals and not covering a resident's urine bag.
F 0578: The facility failed to ensure three residents were informed about advance directives and had completed POLST forms, risking inappropriate medical decisions.
F 0656: The facility failed to develop a care plan for one resident regarding the use of Clopidogrel, risking compromised treatment interventions.
F 0693: The facility failed to hold continuous tube feeding during head of bed repositioning for one resident, risking enteral feeding complications.
F 0698: The facility failed to ensure complete dialysis communication reports for one resident, risking complications.
F 0700: The facility failed to follow bed rail policy for 12 residents by lacking physician orders or care plans for grab bars, risking resident safety.
F 0755: The facility failed to ensure accurate accountability of controlled drugs for three residents due to discrepancies between count sheets and medication records.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days for one resident, risking prolonged exposure to medication side effects.
F 0759: The facility had a medication error rate of 8.82% with three errors during medication administration for two residents, risking compromised therapeutic effects.
F 0800: The facility failed to ensure food safety and sanitation in dietary services including unsanitary equipment, lack of recipe adherence, incomplete emergency menus, and improper thermometer calibration.
F 0802: The facility did not ensure dietary staff competency in food preparation, sanitizing dish machines, and thermometer calibration, risking bacterial contamination.
F 0803: The facility failed to ensure menus met nutritional needs and that pureed diet menus and emergency menus were followed and available.
F 0804: The facility failed to follow standardized recipes for pureed diets, risking altered palatability and nutritional value for twelve residents.
F 0812: The facility failed to maintain safe and sanitary food production and storage practices including leaving old food in microwave, dirty fans, and damaged utensils.
F 0880: The facility failed to implement infection control practices including uncovered soiled linen, improperly disinfected CPAP equipment, unlabeled urinals, improper glove use, and inadequate glucometer disinfection.
F 0908: The facility failed to maintain a coffee machine in safe operable condition with exposed wiring and broken buttons, posing safety risks to staff.
F 0912: The facility failed to ensure resident rooms met minimum square footage requirements, with seven rooms measuring less than 80 square feet per resident.
Report Facts
Medication error rate: 8.82
Residents affected by bed rail deficiency: 12
Residents on fortified diet: 21
Resident rooms below minimum square footage: 7
Residents affected by infection control deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nurse Assistant | Named in dignity and respect deficiency observation. |
| CNA J | Certified Nurse Assistant | Named in infection control deficiency regarding CPAP mask. |
| RN B | Registered Nurse | Named in feeding tube and infection control deficiencies. |
| LVN D | Licensed Vocational Nurse | Named in glucometer disinfection deficiency. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, care plans, infection control, and medication errors. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication accountability deficiencies. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding dietary service deficiencies. |
| Foodservice Director | Foodservice Director | Interviewed regarding dietary service and equipment deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted following a complaint regarding a fall incident involving Resident 1 during transfer using a Hoyer lift, focusing on the facility's failure to complete a fall risk evaluation and improper use of the mechanical lifting device.
Complaint Details
The investigation was complaint-driven, triggered by a fall incident involving Resident 1. The complaint was substantiated as the facility failed to complete a fall risk evaluation and improperly used the Hoyer lift, leading to Resident 1's fall and hospitalization.
Findings
The facility failed to complete a fall risk evaluation for Resident 1 upon admission and did not follow proper procedures for using the Hoyer lift, resulting in Resident 1 falling during transfer and sustaining a brain hemorrhage requiring hospitalization. Interviews and record reviews confirmed inadequate staff training and improper sling use during the transfer.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in Resident 1's fall and serious injury.
Report Facts
Resident weight: 104.2
Resident height: 55
Fall Risk Evaluation date: Dec 16, 2023
MDS assessment date: Dec 22, 2023
Physical therapy treatment note date: Dec 21, 2023
Nursing progress note date: Dec 22, 2023
Training date: Nov 5, 2023
Admission date to hospital: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Operated the Hoyer lift during Resident 1's fall and admitted to improper sling use |
| ROT | Registered Occupational Therapist | Assisted with transfer and held wheelchair during Resident 1's fall |
| LVN B | Licensed Vocational Nurse | Found Resident 1 on the floor after fall and reported incident |
| DON | Director of Nursing | Confirmed fall risk evaluation was not completed on admission |
| MDSC | Minimum Data Set Coordinator | Confirmed fall risk evaluation was not completed on admission |
| DRPT | Director of Rehab and Physical Therapy | Reviewed Resident 1's therapy evaluations and stated rehab staff do not evaluate mechanical lift use |
| DSD | Director of Staff Development | Provided information on staff training and sling size recommendations |
Inspection Report
Routine
Deficiencies: 19
Date: Nov 14, 2022
Visit Reason
Routine inspection of The Villas at Saratoga Skilled Nursing and Assisted Living facility to assess compliance with regulatory standards and resident care requirements.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, medication administration errors, inadequate communication of time changes, incomplete advance directive documentation, failure to notify residents and representatives of hospital transfers and bed hold policies, incomplete assessments for significant changes in condition, inaccurate PASRR screening, improper psychotropic medication monitoring, medication storage issues, failure to provide prescribed therapeutic diets, unsanitary food service conditions, improper garbage disposal practices, infection control lapses, and inadequate resident room sizes.
Deficiencies (19)
F 0550: The facility failed to ensure dignity and respect for Resident 6 when staff did not assist him during lunch while others were eating.
F 0554: The facility failed to assess Resident 49's safety to self-administer medications, risking unsafe medication access.
F 0558: The facility failed to communicate daylight saving time change to Resident 52, potentially affecting resident needs.
F 0578: The facility failed to ensure three residents were made aware of advance directives, risking unfulfilled healthcare wishes.
F 0623: The facility failed to notify residents 32 and 76, their representatives, and ombudsman of hospital transfers.
F 0625: The facility failed to notify residents 32 and 76 or their representatives of the bed hold policy during hospital transfers.
F 0637: The facility failed to complete a Significant Change in Status Assessment for Resident 88 after worsened pressure ulcer and significant weight loss.
F 0645: The facility failed to accurately complete PASRR screening for Resident 50, risking inadequate care for mental illness.
F 0658: The facility failed to follow physician orders for morphine dosing and resident identification during medication administration for Residents 14 and 48.
F 0677: The facility failed to provide necessary nail care for Residents 15 and 18, resulting in long, untrimmed fingernails.
F 0684: The facility failed to provide wound assessment for Resident 6 and implement TED hose use for Resident 50 as per care plans.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident 51 by applying cream inconsistent with physician orders.
F 0758: The facility failed to ensure Residents 24, 64, and 2 were free from unnecessary psychotropic medications due to inadequate monitoring and documentation.
F 0761: The facility failed to properly label and store insulin pens, risking medication errors.
F 0808: The facility failed to provide physician prescribed thickened liquids to Resident 51, risking aspiration.
F 0812: The facility failed to maintain sanitary conditions in the kitchen including wet food containers, dirty utensil drawers, stained cutting boards, and unclean equipment.
F 0814: The facility failed to ensure one garbage dumpster lid was closed, risking pest harborage.
F 0880: The facility failed to implement infection prevention and control practices including COVID-19 screening, hand hygiene, clean linen storage, proper mask disposal, and glove use.
F 0912: The facility failed to ensure seven resident rooms met minimum size requirements of 80 square feet per resident.
Report Facts
Resident rooms below minimum size: 7
Residents affected by advance directive deficiency: 3
Residents affected by hospital transfer notification deficiency: 2
Residents affected by bed hold notification deficiency: 2
Residents affected by psychotropic medication monitoring deficiency: 3
Residents affected by infection control deficiencies: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse B | Licensed Vocational Nurse | Named in medication administration error for morphine dosing. |
| Licensed Vocational Nurse C | Licensed Vocational Nurse | Named in medication administration error for resident identification. |
| Treatment Nurse | Treatment Nurse | Named in infection control lapses and wound care deficiencies. |
| Certified Nursing Assistant Q | Certified Nursing Assistant | Named in failure to provide nail care. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, medication, and care plan issues. |
| Director of Staff Development | Director of Staff Development | Interviewed regarding medication administration and infection control. |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Interviewed regarding assessment and PASRR screening deficiencies. |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding psychotropic medication monitoring and medication storage. |
| Kitchen Supervisor | Kitchen Supervisor | Named in food sanitation deficiencies. |
| Registered Dietitian J | Registered Dietitian | Interviewed regarding food sanitation and therapeutic diet deficiencies. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jan 17, 2020
Visit Reason
The inspection was conducted as a comprehensive annual survey of The Villas at Saratoga Skilled Nursing & Assisted Living facility to assess compliance with regulatory standards.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and comfortable environment, medication administration errors, communication barriers for residents with language needs, medication storage and handling issues, and inadequate room size in some resident rooms. These deficiencies posed potential risks to resident health, safety, and comfort.
Deficiencies (10)
F 0584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including peeling paint scratches on resident doors and inadequate hallway temperatures causing resident discomfort.
F 0584: CNA failed to communicate Resident 59's complaint of feeling cold to licensed nurse and maintenance, violating facility policy on work orders.
F 0658: The facility failed to administer prescribed medications as ordered for Residents 59 and 134, including PRN cough medicine and PRN pain medications, potentially causing discomfort and delayed treatment.
F 0676: The facility failed to provide communication tools and services for Residents 10 and 26 with language barriers, resulting in communication difficulties and potential delays in care.
F 0684: The facility failed to provide medication as prescribed for Resident 44, omitting Protonix from 11/19/19 to 12/11/19, which may have contributed to hospitalization.
F 0755: The facility failed to follow pharmacy services policies including timely delivery of medications for Resident 188, inaccurate controlled substance accountability for Residents 134 and 31, and duplicate emergency kits at nurse station.
F 0758: The facility failed to act timely on psychiatry recommendations for Resident 4, resulting in unnecessary psychotropic medication use.
F 0759: The facility's medication error rate was 27.59%, with errors including missed medications for Residents 188, 67, and 26, compromising resident safety.
F 0761: The facility failed to properly monitor vaccine storage temperatures, had expired medications in stock, and licensed nurses left medications unattended, risking resident safety.
F 0912: The facility failed to ensure resident rooms met minimum size requirements of 80 square feet per resident in seven rooms, potentially compromising care.
Report Facts
Medication error rate: 27.59
Room size: 71.5
Room size: 78
Medication doses missed: 4
Medication doses missed: 3
Medication doses missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Left medications unattended including Duoneb and Humalog on Resident 67's bedside |
| LVN C | Licensed Vocational Nurse | Left eye drops and sodium chloride medication unattended on two occasions |
| Director of Nursing | Director of Nursing | Confirmed medication administration and storage deficiencies and provided interviews on multiple findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed duplicate emergency kits and confirmed vaccine storage monitoring issues |
| Social Services Director | Social Services Director | Provided information on communication barriers and psychiatry assessment delays |
| Pharmacy Director | Pharmacy Director | Confirmed medication delivery expectations and emergency kit policies |
Report
January 9, 2026
Report
September 18, 2025
Report
April 4, 2025
Report
January 9, 2025
Report
September 18, 2024
Report
September 16, 2024
Report
August 22, 2024
Report
May 2, 2024
Report
October 10, 2023
Report
October 4, 2023
Report
October 4, 2023
Report
April 18, 2023
Report
September 27, 2022
Report
May 24, 2022
Report
May 24, 2022
Report
April 8, 2022
Report
March 22, 2022
Report
March 18, 2022
Report
March 17, 2022
Report
July 22, 2021
Report
July 22, 2021
Report
July 22, 2021
Report
July 22, 2021
Viewing
Loading inspection reports...
