Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Childrens Hc Org No Ca Saratoga Pediatric Subacute during CMS and state inspections, most recent first.
A facility failed to develop specific, individualized, resident-centered care plans for side rail use for 12 residents who had orders for padded or full side rails, often for seizure precautions or safe sleep/rest. Observations showed the residents with side rails in place, and record review confirmed that none of the care plans addressed the side rails specifically; the MDSC verified the omission and the ADM acknowledged the issue.
Missing Dryer Lint Tray Cleaning Logs: The laundry dryer lint tray cleaning monitoring sheet had missing NOC shift entries for multiple dates for 2 large dryers. The MDIR verified that laundry staff were expected to check and clean dryer lint after use, and the facility policy stated to check for lint and clean accordingly to avoid fire.
Medication administration errors resulted in a 14.29% error rate during observed med passes. An LVN combined seizure meds and gave them together via G-tube without flushing between each med, and an RN crushed glycopyrrolate and tizanidine together, mixed them in water, and administered them via G-tube. Facility policy stated crushed meds are not to be mixed and should be given separately with flushes between each med.
Expired hydralazine was found in a med cart for a resident with an active PRN order for hypertension, and three expired blood glucose control solutions were found in an active-use supply area of the med room. The IP confirmed the items were expired and should have been discarded, and the MDSC stated that expired medication should not remain in the cart and that expired control solution could cause false calibration or inaccuracies.
A facility failed to report an alleged abuse incident involving a resident with complex medical conditions. The resident was involved in a physical altercation with an RT, witnessed by staff, who reported it to the Administrator and police. Despite evidence and policy requirements, the Administrator did not report the incident to the State Survey Agency, concluding it was not abuse.
A facility failed to follow its policy by not attempting alternative measures before using bed rails for 20 residents, as observed and confirmed by staff interviews. This non-compliance with the policy potentially placed residents at risk of entrapment and serious injury.
The facility failed to maintain sanitary conditions in the kitchen, with expired food items, missing temperature log entries, and moldy produce. Additionally, spice containers lacked expiration dates, cutting boards were damaged, and a fan was unclean. These issues were confirmed by the dietary supervisor, indicating non-compliance with facility policies and FDA guidelines.
The facility failed to maintain clean filters on oxygen concentrators for five residents with respiratory conditions, as observed by a respiratory therapist. The facility's service manual required weekly cleaning of the filters, but this was not adhered to, posing a potential infection risk.
A facility failed to conduct a background check for a newly hired CNA, as required by its abuse prevention policy. The CNA was hired without the necessary screening, which was confirmed by the DSD after consulting with human resources. This lapse had the potential to endanger residents.
A resident's Lansoprazole ODT was improperly administered by crushing the tablet, contrary to guidelines. Both an LVN and an RN were involved in this repeated error, despite clear instructions not to crush the medication. The facility's policy emphasized adherence to guidelines, which was not followed.
A facility failed to label and discard a multi-dose vial of lorazepam, a controlled medication, within the required 28 days after opening. The vial, found in the medication refrigerator without an open date, had been opened four months prior. RN B confirmed the oversight, and the Consultant Pharmacist emphasized the importance of discarding vials to prevent cross-contamination.
Missing individualized care plans for side rail use
Penalty
Summary
The facility failed to develop and implement specific, individualized, resident-centered care plans for the use of side rails for 12 residents. During observations, these residents were seen with side rails in place, including padded upper side rails, four side rails, or half side rails, while in bed or seated in wheelchairs in their rooms. The residents observed included individuals who were calm, comfortable, sleeping, or not talking at the time of observation. Record review showed each of the 12 residents had an order for side rails or padded side rails as part of a hospital bed setup, often described as being for safe sleep or rest environment or to prevent injury during seizure precautions. The residents had diagnoses including anoxic brain damage, traumatic brain injury, cerebral palsy, traumatic subarachnoid hemorrhage, intracerebral hemorrhage, myotonic muscular dystrophy, necrotizing enterocolitis, diffuse traumatic brain injury, encephalitis/encephalomyelitis, respiratory failure with hypoxia, and facioscapulohumeral muscular dystrophy. Review of the care plans for Residents 16, 19, 4, 27, 5, 1, 29, 6, 32, 14, 24, and 12 showed that none had a specific, individualized, resident-centered care plan for the side rails. The MDS coordinator verified this for the residents reviewed, and the administrator acknowledged that the residents should have separate, specific, individualized, resident-centered care plans for their side rails.
Missing Dryer Lint Tray Cleaning Logs
Penalty
Summary
The facility failed to ensure the laundry dryer lint tray cleaning monitoring sheet was completed for the nocturnal shift for multiple dates in February 2026. During observation of the laundry room on 2/10/26 at 11:05 a.m., missing logs were identified for the NOC shift on 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/6/26, and 2/9/26 for the facility’s 2 large dryers. The missing entries were for the removal of dryer lint from the lint trays after use. During interview on 2/10/26 at 11:07 a.m., the maintenance director verified the facility’s laundry shifts and stated that laundry staff should check, clean, or replace dryer lint after using the dryers to avoid overheating. He confirmed the missing NOC shift signature logs on the monitoring sheet and stated there should be no missing signature logs to show that lint was checked, cleaned, or replaced as needed after dryer use. Review of the facility’s undated Laundry Procedure stated, “Check for lint and clean accordingly to avoid fire.”
Medication Administration Errors During G-Tube Passes
Penalty
Summary
The facility had a medication error rate of 14.29% after 4 medication errors were observed out of 28 opportunities during medication passes for two residents. During a medication pass for Resident 8, an LVN prepared topiramate 25 mg dissolved in 3 ml of water and 3 ml of levetiracetam for seizure management, then combined the medications in one purple syringe and administered them together via G-tube without flushing between each medication. The LVN confirmed that the medications were combined and stated that he did not flush between each medication, only before and after the final administration. During a medication pass for Resident 16, an RN prepared glycopyrrolate 1 mg and two and a half tablets of tizanidine 2 mg, crushed both tablets together, dissolved them in 10 ml of water, and administered the mixture via G-tube. The RN confirmed that the medications were crushed together and stated that she only separates medications when administering narcotics. A concurrent interview and record review with another RN stated that medications given via G-tube should be administered separately with water flushes in between, and that mixing medications could cause a possible drug-to-drug interaction. The facility policy on enteral tube medication administration stated that crushed medications are not to be mixed together and should be administered separately with flushing between each medication.
Expired Medication and Control Solutions Found in Medication Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles when an expired hydralazine tablet remained in Med Cart B for Resident 3. During inspection of the cart with the infection control preventionist, the expired medication was found in the medication compartment, and the discard date had passed. Resident 3 had an active order for hydralazine HLC oral tablet 10 mg via J-tube every 6 hours as needed for hypertension. The facility also failed to remove expired control solutions from an active-use supply area in the medication room. During inspection with the infection control preventionist, one Assure dose control solution and two [NAME] control solutions were found expired, and the infection control preventionist stated that the solutions should be discarded. The minimum data set coordinator stated that expired medication should not be stored in the medication cart and that an expired control solution could lead to false calibration or inaccuracies. The facility policy stated that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency, which had the potential to delay investigations and compromise the resident's safety. The resident, who was admitted with complex medical conditions including congenital central alveolar hypoventilation syndrome, short bowel syndrome, and chronic respiratory failure, was involved in an incident with a Respiratory Therapist (RT). During the incident, the RT reportedly held the resident's forearms and placed him on the bed after the resident lunged at him. A Registered Nurse (RN) witnessed the RT holding the resident's wrists and reported the incident to the Administrator and the police. Despite the RN's report and the presence of red markings on the resident's wrists, the Administrator did not report the incident to the State Survey Agency, concluding it was not abuse. The facility's policy requires that any reasonable suspicion of abuse be reported to the appropriate authorities, but this protocol was not followed. The Director of Staff Development confirmed that the Administrator informed the staff that the incident was not considered abuse based on his investigation, despite conflicting accounts from staff members who witnessed the event.
Failure to Attempt Alternative Measures Before Bed Rail Use
Penalty
Summary
The facility failed to adhere to its Bed/Side Rails policy for 20 out of 22 residents by not attempting alternative measures before applying bed side rails. This oversight was identified through observations, interviews, and record reviews. The policy requires that alternative interventions be utilized prior to the use of bed rails, but this step was not followed, potentially placing residents at risk of entrapment and serious injury. During observations conducted on various dates, multiple residents were found in their beds with side rails up, without evidence that alternative measures had been attempted. For instance, Resident 11 had an order for upper side rails dated February 7, 2023, but the rationale and consent form dated December 19, 2023, indicated that no alternative measures were tried. Similar findings were noted for other residents, such as Resident 1, Resident 2, and Resident 181, among others, where the documentation showed that alternative measures were not considered before the application of side rails. Interviews with facility staff, including the rehabilitation supervisor and the director of nursing, confirmed that alternative measures were not attempted for the residents prior to the use of side rails. The rehabilitation supervisor stated that alternative measures would only be considered if the responsible party refused consent for side rails, which contradicts the facility's policy. The director of nursing acknowledged the failure to attempt alternative measures for the affected residents, further highlighting the facility's non-compliance with its own policy.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially lead to food-borne illnesses for residents. During an inspection, it was observed that food items such as potato salad, leftover beans, and an open bag of broccoli were kept beyond their expiration dates. The facility's policy indicated that opened food items should be used within three days, but this was not adhered to. Additionally, temperature logs for two refrigeration units had missing entries, which should have been documented twice daily according to the facility's policy. Five opened spice containers lacked expiration dates, and three cutting boards had deep cut marks, making them difficult to clean and sanitize effectively. Further observations revealed that five red onions and four yellow onions were moldy, and six potatoes were soft and wrinkled, indicating spoilage. An electric fan in the kitchen had dark particles on its blades and grills, suggesting a lack of cleanliness. These conditions were confirmed by the dietary supervisor during the inspection. The facility's policies on food safety and sanitation, as well as the FDA Food Code, were not followed, leading to these deficiencies.
Infection Control Deficiency: Dusty Oxygen Concentrator Filters
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the dusty filters on oxygen concentrators for five residents. These residents, identified as having respiratory failure or ventilator dependence, had physician orders for oxygen to maintain their oxygen saturation levels above 92%. During observations conducted with a respiratory therapist, it was confirmed that the filters on the oxygen concentrators for these residents were dusty, which could potentially contribute to the spread of infection within the facility. The facility's service manual for the oxygen concentrators specified that the air filters should be cleaned every seven days. However, this protocol was not followed, as observed in the cases of the five residents. The respiratory therapist acknowledged that the filters should be kept clean, indicating a lapse in adherence to the facility's infection control procedures. This oversight in maintaining clean equipment for residents with critical respiratory conditions highlights a significant deficiency in the facility's infection prevention and control program.
Failure to Conduct Background Check for CNA
Penalty
Summary
The facility failed to implement its abuse prevention policy by not obtaining a background check for one of its certified nursing assistants (CNA C) upon hiring. CNA C was hired on February 8, 2024, without a background screening, which was confirmed by the director of staff development (DSD) after checking with human resources. The facility's policy mandates that reference and background checks be obtained upon hiring to ensure that no individual convicted of resident abuse or misappropriation of resident property is employed. This oversight had the potential to put residents at risk for abuse.
Improper Administration of Lansoprazole ODT
Penalty
Summary
The facility failed to ensure proper administration of medication for a resident, specifically regarding the administration of Lansoprazole Oral Disintegrating Tablet (ODT). The deficiency was identified when a Licensed Vocational Nurse (LVN) was observed crushing the Lansoprazole ODT 30 mg tablet and mixing it with water before administering it to the resident. This action was contrary to the manufacturer's guidelines, which specify that the tablet should not be crushed. The LVN stated that she crushed all of the resident's medications according to the physician's orders, but acknowledged the error upon reviewing the facility's Nursing Drug Handbook. Further investigation revealed that a Registered Nurse (RN) also administered the Lansoprazole ODT tablet by crushing it and mixing it with water, despite the pharmacy label clearly indicating not to chew or crush the tablet. The resident's physician's order specified the administration of Lansoprazole 30 mg via G-tube once a day for gastritis. The Medication Administration Record showed that both the LVN and RN had administered the medication incorrectly on multiple occasions. The facility's policy on medication administration emphasized compliance with recommended guidelines to ensure safety and efficacy, which was not adhered to in this case.
Failure to Label and Discard Multi-Dose Medication Vial
Penalty
Summary
The facility failed to ensure proper labeling and storage of a multi-dose medication, specifically a 10 mL vial of lorazepam, which is a controlled medication used to treat seizures and agitation. During an observation and record review, it was found that the vial in the medication refrigerator lacked an open date, despite being opened four months prior. Registered Nurse B acknowledged the oversight and confirmed with the pharmacy that the vial should have been discarded 28 days after being punctured. The Consultant Pharmacist reiterated that multi-dose vials should be discarded 28 days after opening to prevent cross-contamination. The facility's policy required all multi-dose vials to be dated and initialed upon opening and discarded within 28 days unless otherwise specified on the label.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 399 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saratoga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saratoga Retirement Community Health Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Westwood Post Acute | 1.6 mi | ★★★★★ | 12 | 0 |
| The Villas At Saratoga Skilled Nsg & Assisted Lvg | 2 mi | ★★★★★ | 14 | 0 |
| Baywood Post Acute | 2.3 mi | ★★★★★ | 0 | 0 |
| Camden Postacute Care, Inc | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Childrens Hc Org No Ca Saratoga Pediatric Subacute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.