Health inspection·October 12, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, shower schedule review and interview the facility failed to ensure residents were provided the opportunity to choose their shower schedule and/or failed to ensure residents were offered choices related to meals. This affected one resident (#32) of one resident reviewed for choices and one resident (#11) of one resident reviewed for dialysis. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 08/27/22 with diagnoses including nondisplaced fracture of the surgical neck of the left humerus, hypertension and heart disease. Review of the physician's orders revealed an order, dated 08/27/22 to maintain sling to the left arm and may remove for hygiene. Review of the undated document titled MDS Information and Resident History revealed the resident preferred a shower and the preferred time of day was 9:00 A.M. to 10:00 A.M. Review of the resident preferences plan of care, initiated on 08/29/22 revealed interventions including make sure she gets a shower between 9-10:00 A.M. as per their request Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the shower documentation from 09/13/22 through 10/05/22 revealed the resident received a shower on 09/20/22, 09/27/22, 10/04/22 and 10/05/22. Review of the undated document titled Shower Schedule (Hall Name) Night Shift revealed the schedule was based off resident preferences, do not change). The document reflected Resident #32 was to receive a shower three days a week on Monday, Wednesday and Friday on night shift (6:00 P.M. to 6:30 A.M.) On 10/03/22 at 12:07 P.M. interview with Resident #32 revealed she doesn't get showered as often as she would like and she would like to receive showers more often. A follow-up interview on 10/05/22 at 11:00 A.M. revealed the resident received showers on night shift which she does not like because then she goes to bed with wet hair and her hair was a mess the following morning. On 10/04/22 at 4:10 P.M. interview with State Tested Nursing Assistant (STNA) #32 verified the resident was to be showered three times a week on night shift and the showers were documented in the facility electronic/computer system. The STNA revealed the facility did not utilize shower sheets or other paper documentation for showers. On 10/05/22 at 1:59 P.M. interview with the Director of Nursing (DON) verified the resident was not provided showers per her preference as she was scheduled on night shift and the resident's MDS information, which was asked on admission and her plan of care both indicated the resident wanted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 2 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showered between 9-10:00 A.M. The DON also verified the resident had only received four showers in the last 30 days and she was scheduled to received showers three times a week. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity and chronic kidney disease requiring dialysis. Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. His current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note revealed for registered dietician to follow and address nutritional concerns as appropriate. Review of Resident #11's meal intakes on hemodialysis days (M-W-F) from 09/02/22 to 10/03/22 revealed the resident had zero intakes for breakfast on the 7th, 9th, 12th, 14th, 19th, 21st, 23rd, 26th, 28th, 30th of September and 10/03/22. Review of Resident #11's nutritional plan of care revealed the resident's goal was to maintain meal intakes of 66% or greater. Interventions included to honor food preferences and offer meal replacement for poor intakes or upon request. Review of Resident #11's current orders for 10/2022 revealed orders for hemodialysis days Monday, Wednesday, and Friday at 7:00 A.M. and a diet order was for a non-gastric irritating (no OJ, tomatoes or fried foods) regular texture diet with thin (regular) liquids. Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he only received two meals (lunch and dinner) on dialysis days. The resident revealed the dialysis center does not permit food in the center so he could not even take snack to eat, and the nursing home kitchen was not open early enough to make him a breakfast before he left for dialysis. The resident reported he would like something to eat besides cold cereal and peanut butter sandwiches, which was all the staff had access to in the morning before he left to offer him. The resident verified he was not offered any other choices of breakfast items to eat prior to go to dialysis. Interview on 10/04/22 at 2:32 P.M. and 3:09 P.M., with the Dietary Manager (DM) #4 and Resident #11 revealed the DM was not aware the resident was not eating breakfast on dialysis days. The direct care staff had never reported to her he was not eating breakfast on those days. The DM confirmed the kitchen staff do not come in early enough to make him a hot breakfast. The resident reported staff were getting him up and ready around 5:30 A.M. and he leaves between 6-6:30 A.M. for his 7:00 A.M., chair time. The DM confirmed residents were not permitted to eat at dialysis center and the dialysis center had called her reported to remind the resident not to bring food to the dialysis center. Interview on 10/04/22 at 3:02 P.M., with STNA #28 confirmed Resident #11 doesn't get a breakfast meal or eat anything in the mornings prior to going to dialysis. The STNA reported one of the reasons was the kitchen was not open until 6:00 A.M. and the second reason was they used to offer him a peanut butter sandwich in the morning, but he was declining them. The STNA reported the only breakfast (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 3 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 items they have to offer him in the mornings were cold cereal and peanut butter sandwiches. Level of Harm - Minimal harm or potential for actual harm Interview on 10/05/22 at 2:44 P.M., with Dietician #80 revealed she was not aware the resident was not eating breakfast on dialysis days, but stated she was not too worried because he had snacks in his room, however if a resident was not eating, she would inquire into why they were not eating. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 4 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure resident health concerns were timely reported to the physician. This affected one resident (#32) of five residents reviewed for range of motion. Findings include: Review of Resident #32's hospital history and physical, dated 08/22/22 revealed the resident had a past medical history of thyroid disease. Review of Resident #32's medical record revealed an admission date of 08/27/22 with diagnoses including nondisplaced fracture of the surgical neck of the left humerus, hypertension and heart disease. Review of the physician's orders revealed an order, dated 08/27/22 to maintain sling to the left arm and may remove for hygiene. There were no orders for thyroid medication or thyroid laboratory monitoring. Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review revealed the resident did not have thyroid disease coded on the MDS as a diagnosis. On 10/03/22 at 11:47 A.M. interview with Resident #32 revealed she had been feeling nervous, had been crying and unable to sleep. The resident shared she had a history of low thyroid and had since she was [AGE] years old. The resident stated she had taken medication prior to COVID but then COVID affected getting her medications refilled and she had not taken the medication for some time. The resident also revealed she informed the nurse at the facility she needed checked as she thought her thyroid was out of whack and the reason she had been having issues. As the interview was occurring, Licensed Practical Nurse (LPN) #53 was walking in the hall and stopped to ask the resident what she needed. The resident informed the nurse she thought her thyroid was off and the nurse informed the resident she would call and update the resident's physician. Further review of the medical record as of 10/05/22 revealed no evidence LPN #53 notified the physician of the resident's concern. On 10/05/22 at 2:13 P.M. telephone interview with LPN #53 verified she did not notify Resident #32's physician regarding her concerns with her thyroid levels. The LPN stated she should have notified the physician on 10/03/22, when the resident reported to her the concerns she was having regarding her thyroid. On 10/05/22 at 3:03 P.M. interview with the Director of Nursing (DON) verified LPN #53 should have contacted the resident's physician about her concerns regarding her thyroid. The DON stated she spoke with the resident's medical care provider and she ordered lab studies to be completed for the resident. On 10/05/22 at 3:03 P.M. interview with Registered Nurse (RN) #57 verified the MDS assessment did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 5 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not accurately reflect the resident's thyroid disease and verified the hospital documentation listed thyroid disease as part of the resident's medical history. Review of the undated Physician Notification of Changes in Resident Status Policy revealed specific signs, symptoms and laboratory values suggestive of acute illness needing immediate medical assessment should be reported to the attending physician by the staff as soon as possible after they were identified. All acute changes in resident status reported to the medical staff on an immediate basis would be assessed and documented in the medical record by the nursing staff. Specific signs/symptoms and lab values suggestive of sub-acute illness shall be reported to the attending physician but not on an immediate basis. All subacute changes in resident status reported to the physician on a non-immediate basis would be assessed and documented in the medical record. If a physician does not respond by the end of the shift, the information would be given to the oncoming shift who would be responsible for follow-up. Event ID: Facility ID: 366416 If continuation sheet Page 6 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to prevent an incident of misappropriation of personal property involving Resident #11. This affected one resident (#11) of five residents reviewed for misappropriation. Residents Affected - Few Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 7 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 social security card. Level of Harm - Minimal harm or potential for actual harm Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Residents Affected - Few Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 8 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Residents Affected - Few Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 9 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to implement their abuse/misappropriation policy and procedure to prevent an incident of misappropriation, to ensure the incident was thoroughly investigated and to ensure the incident was reported to the State agency. This affected one resident (#11) of five residents reviewed for misappropriation. Residents Affected - Few Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 10 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 11 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 12 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to report an allegation of misappropriation of personal property involving Resident #11 to the State agency as required. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 13 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State Tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 14 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 15 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #18, who was dependent on staff for activities of daily living (ADL) care received proper and adequate oral care. This affected one resident (#18) of one resident reviewed for activities of daily living (ADL). Residents Affected - Few Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, cerebrovascular disease, multiple sclerosis, mood affective disorder, osteoporosis, dysphagia and Alzheimer's Disease. Review of Resident #18's last dental note, dated 01/23/18 revealed the resident had lots of debris and inflammation. The note revealed the resident needed assistance with brushing teeth and gums. Patient was uncooperative; unable to clean teeth today and would try with next visit. Review of Resident #18's Minimum Data Set (MDS) 3.0 assessment, dated 07/26/22 revealed the resident had severe cognitive impairment, had no behaviors or rejection of care. The resident was assessed to be total dependent on one staff member for personal hygiene including brushing her teeth. The resident had obvious or likely cavity or broken natural teeth. Review of Resident #18's personal hygiene plan of care revealed staff were to brush the resident's teeth every morning and night and as needed. Further review of Resident #18's plan of care revealed the resident refused medication at times and spits them out. However, there was no evidence the resident refused oral care. Review of the nurse aide tracking documentation for personal hygiene, dated 09/03/22 to 10/03/22 revealed the resident was mostly dependent of staff for hygiene care. Observation on 10/03/22 at 3:16 P.M., revealed Resident #18 had plaque build-up noted on the teeth, The resident's teeth were also discolored with one tooth missing on the top. There was no evidence of oral hygiene products visible in the resident's room or bathroom. Observation of Resident #18 and interview on 10/06/22 at 2:27 PM with Licensed Practical Nurse (LPN) #51 and State Tested Nursing Assistant (STNA) #28 confirmed the resident had no oral care supplies (toothbrushes, swabs, mouth wash, toothpaste) in the room. Both staff members confirmed the resident's teeth were in poor condition with plaque buildup. The STNA reported he thought one of the Hospice aides brought her own oral hygiene supplies to do mouth care but was not sure if the rest of the Hospice aides did. The Hospice aides visit three times a week per LPN #51. STNA #51 reported he only used mouth wash on a swab when he provided mouth care to Resident #18 even though she had her own natural teeth. STNA #28 reported the resident would often tell you no if you asked her any questions and then she would play possum, (acting like she is asleep). An additional observation on 10/11/22 at 10:11 PM with STNA #44 revealed the STNA reported she had not provided mouth care to the resident in the past but was told to use a mouth swab with mouth wash on it to clean the resident's teeth. The aide reported she should be using tooth paste in addition since the resident had her natural teeth. The STNA reported she would not just use mouth wash to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 16 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete clean her own natural teeth. The STNA #44 then removed an unopened box of tooth paste from the dresser and applied it to the swab. The STNA asked the resident if she could provide oral care and the resident responded no. The STNA did not encourage the resident to participate or help with her own oral care. Interview on 10/11/22 at 11:04 A.M., with LPN #51 revealed the resident refused to open her mouth for the dentist in 2018 and she had not been seen by the dentist since. The resident had consented to see the dentist and she should have been seen in 2021 and 2022. The dentist did not visit in 2020 due to COVID-19. The LPN reported she would make sure the resident was on the list to be seen at the next visit. Event ID: Facility ID: 366416 If continuation sheet Page 17 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to develop and implement comprehensive and individualized restorative nursing service plans to ensure interventions and treatments were provided to residents to prevent a decline in range of motion (ROM) or maintain current ROM function. This affected two residents (#1 and #11) of five residents reviewed for mobility. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's Disease and limited range of motion. Review of Resident #1's annual Minimum Date Set (MDS) 3.0 assessment, dated 09/20/22 revealed the resident had limited range of motion to one side of the upper extremity. Review of Resident #1's current orders, dated 10/2022 revealed an order (dated 02/04/22) to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed. The order indicated to keep wash cloth in place as tolerated throughout the day and at night. Review of Resident #1's risk for skin breakdown and risk for impaired functional range of motion care plans revealed the resident was to wear a rolled cloth to the right hand and if not able to tolerate, let therapy know and to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Review of the nursing task list dated 09/11/22 to 10/11/22 revealed to gentle perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Further review revealed on 10/11/22 staff documented at 2:25 P.M. the washcloth was in-place. Observation on 10/11/22 at 2:48 P.M., with Licensed Practical Nurse (LPN) #51 revealed the resident was resting in bed and no washcloth was noted in the right hand or bed. The resident would not let the LPN touch her hand and kept pulling it way. The hand was noted to be contracted. Interview on 10/11/22 at 2:51 P.M., with LPN #51 revealed she had spoken to the resident's aide, and she reported the resident had gotten ketchup on the washcloth at lunch and she removed it and forgot to replace it. Interview on 10/11/22 at 3:05 P.M., interview with the Director of Nursing (DON) revealed she had just helped the aide place a new washcloth in the right hand it was difficult, but they were able to slide the washcloth in her hand. The DON verified staff had documented at 2:25 P.M., the washcloth was in-place, however the observation at 2:51 P.M., revealed the washcloth was not in-place, and the staff reported to LPN #51 she had removed it after lunch and forgot to replace it. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including respiratory failure, heart failure, osteoarthritis of knee, diabetes, and difficulty walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 18 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #11's quarterly MDS 3.0 assessment, dated 07/12/22 revealed the resident's cognition was intact. The assessment revealed the resident had behaviors or refusal of care and had had impairment to his bilateral lower extremities. Review of a therapy referral to restorative form, dated 05/25/22 revealed Resident #1 was referred for active range of motion (AROM) to the right and left upper and lower extremities, two sets and ten repetitions. The number of times per day was blank. Review of Resident #11's task documentation, dated 05/26/22 revealed AROM to bilateral upper and lower extremities. There was no indication on how many repetitions or sets or how many times a week to complete. Record review revealed the resident had a current limited mobility plan of care. The plan revealed the resident would receive AROM to the bilateral upper and lower extremities, two sets of ten repetitions for at least 15 minutes daily. Interview on 10/03/22 at 2:35 P.M., with Resident #11 revealed staff were not assisting him with range of motion exercises and he had limitations to his lower extremities. Interview on 10/04/22 at 3:02 P.M., with STNA #28 revealed floor staff were responsible for restorative therapy and ROM. STNA #28 reported Resident #11 would allow staff to do ROM with his upper extremities, however he would not allow you to touch his legs. The resident would scream out in pain even before you touched him. Interview on 10/05/22 at 12:30 P.M., with Resident #11 and the DON revealed he would like to have therapy, but was concerned his insurance would not cover it. The resident revealed he had been taking pain medication three times a day and had seen a doctor for steroid injections at one time. Interview on 10/05/22 at 2:51 P.M., with Registered Nurse (RN) #57 revealed she was new to the program and was not aware resident was not participating in the lower leg AROM program. The RN confirmed the program under the task section for the aides to document did not include the number of repetitions, sets, time, or frequency to complete each upper and lower extremity exercise. The RN reported under the task section, the upper extremity and lower extremities had been separated and should have included two sets of 10 reps for 15 minutes; six to seven times a week. The RN reported she would update therapy on the resident's refusal to perform AROM to the lower extremity and update the task order for the aide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 19 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including depression, Alzheimer's Disease and schizoaffective disorder. The diagnosis of Parkinson's disease was added to the resident's medical record in July 2022. Residents Affected - Few Review of the resident requires a therapeutic nutrition intervention plan of care dated 12/10/20 revealed interventions including honor food preferences, offer a meal replacement for poor intakes or upon request, offer a nourishing bedtime snack daily, provide diet as ordered and record intakes every meal and provide supplements as order- Mighty Shakes twice a day. Review of Resident #21's weights revealed: On 05/04/22 216 pounds On 06/10/22 216 pounds On 07/07/22 210 pounds On 08/05/22 202 pounds On 09/11/22 194 pounds a 7.8% weight loss (16 pounds) since 07/07/22. No additional weight monitoring was noted in the medical record. Review of the resident requires a pureed diet with nectar thick liquids plan of care, dated 07/28/22 revealed interventions including consult speech as needed and follow recommendations provided, observe for difficulty swallowing, holding food in mouth, prolonged swallowing time. repeated swallows ER bite, coughing, throat clearing, drooling, pocketing food in mouth and excessive chewing, provide diet texture as ordered. Review of the quarterly MDS 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and the resident was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months per the MDS assessment. Review of the physician's orders revealed a pureed diet with honey thickened liquids, dated 09/07/22 (following safe swallowing instructions from a modified barium swallow), a magic cup with meals dated 09/16/22 and to eat all meals in the dining room dated 09/26/22. The resident was receiving mighty shakes (supplement) two times a day from 07/29/22 through 09/16/22. Review of the resident's supplement intakes for September and October 2022 revealed the nurse documented with a check mark indicating the resident received his nutritional supplement but did not document the percentage consumed. Review of the nutrition progress note dated 09/15/22 revealed the physician was notified of the weight loss of 22.2 pounds (10.3 % in three months). Current weight 193.8 pounds with a body mass index of 25.6. Meal intakes average 68% yet ongoing weight loss was noted. Resident's diet texture was downgraded to puree with honey thickened liquids. Mighty shakes ordered twice a day. The registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 20 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm dietician (RD #80) recommended to discontinue mighty shakes twice a day and provide magic cups three times a day. On 10/05/22 at 12:28 P.M. Resident #21 was observed seated in his wheelchair in the dining room. The resident was being assisted with his meal by a family member. Residents Affected - Few On 10/05/22 at 5:25 P.M. Resident #21 was observed seated in his wheel chair in the dining room. The resident was feeding himself and was being provided verbal cues from staff in the dining room. The resident was observed to eat his magic cup during the meal and was provided the appropriate diet and fluid consistency. On 10/06/22 at 10:42 A.M. interview with RD #80 revealed the resident had experienced significant weight loss and recently had a change in his fluid consistency from nectar to honey thickened and his diet changed to puree texture in July 2022. The RD stated speech therapy was working with the resident and verified she had not observed the resident eating since she was not always in the facility during meal times. The RD stated she did not recommend changing the resident from monthly weights to weekly weights despite the resident's identified significant weight loss of 10.3 % or 22.2 pounds in three months. On 10/06/22 at 11:15 A.M. LPN #51 and State Tested Nursing Assistant (STNA) #26 were observed to weigh Resident #21 while in his wheelchair. The resident and chair weighed 242.4 pounds and this was verified by LPN #51. At 11:20 A.M. LPN #51 weighed only the resident's wheelchair and it weighed 52.8 pounds. This indicated the resident now weighed 189.6 pounds, a 4.2 pound weight loss since 09/11/22. This was verified with LPN #51 at the time of the observation. On 10/06/22 at 11:40 A.M. a follow-up interview was completed with RD #80. The RD verified the resident's additional weight loss and felt all hope is not lost and the resident's weight loss could have been worse. The stated she would consider the resident nutritionally complex and would need to re-evaluate him. She indicated she used information such as observing the resident eat, weights and labs to determine if the facility was meeting the resident's nutritional needs. On 10/11/22 at 10:50 A.M. a follow-up interview was completed with RD #80 which revealed she spoke to someone (she was unable to recall the staff member) regarding the resident's weight fluctuations and felt this may be due to excess fluid but had no additional information to support her thought of excess fluid volume. The RD stated the resident was weighed over the weekend but the weight was not documented. Lastly, the RD stated more frequent weights may be upsetting to residents and some don't like seeing the scale and being weighed so she didn't want to upset the residents by weighing them more often than monthly. On 10/06/22 at 12:35 P.M. telephone interview with the Speech Therapist (ST) #75 revealed she wasn't seeing the resident any longer and discharged him about two weeks ago with recommendations for him including to be up at 90 degrees, go to the dining room for meals, close supervision while eating, feed only when alert, small bites and sips while eating and alternate liquids and solids. She stated she felt his Parkinson's disease may be progressing and this caused a lot of his nutritional issues and his participation varied greatly related to his fatigue level and how tired he was. If the resident was fatigued and needed assistance he could go to bed and have the head of the bed elevated 90 degrees. ST #75 revealed the resident does very well but how well he does depends on him and his day. The ST did not feel the resident had any additional therapy needs such as occupational therapy at the time of discharge from ST. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 21 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm On 10/06/22 at 6:00 P.M. interview with the DON verified the resident had experienced significant weight loss and diet changes as well as the addition of some nutritional interventions. The DON verified the resident's weight loss should have been identified timely and monitored more closely due to his complex issues such as dysphagia, diet changes and co-morbidities. The DON stated she planned to discuss the resident with the dietician and place the resident on weekly weights to ensure his needs were being met. Residents Affected - Few A follow-up interview on 10/11/22 at 11:04 A.M. verified the resident's nutrition care plan was not updated to reflect the resident's supplement change or consistency of his liquids being changed from nectar thick to honey thick. The DON also verified there was no indication the resident was experiencing any fluid overload as he was not experiencing any shortness of breath, edema or adventitious lung sounds. Review of the Weight Policy, reviewed and revised 07/13/16 revealed residents would be weighed upon admission within 48 hours and then once a month or as ordered by the physician. Available information would be reviewed for possible reasons for weight loss. Physicians would be notified of any weight change of five percent or more in a month, seven and a half percent in three months and 10 % in six months and all necessary interventions would be implemented as ordered. Based on observation, record review, review of dialysis dietary notes, facility policy and procedure review and interview the facility failed to ensure residents were assessed and timely identified related to continued significant weight loss. The facility also failed to ensure residents receiving hemodialysis had accurate diet and fluid restriction orders. This affected two residents (#11 and #21) of three residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypertrophy of kidney, obstructive and reflux uropathy, Vitamin D deficiency, constipation, heart disease, diabetic, hyperlipidemia, morbid obesity, chronic kidney disease requiring dialysis. Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. The resident's current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note indicated registered dietician to follow and address nutritional concerns as appropriate. Review of a dialysis dietary note, (requested by surveyor), dated 09/26/22 revealed to reinforce one liter fluid restriction, limit salt use, and encourage oral nutrition supplements in the facility with high protein food choices. Further review of the dialysis dietary note, dated 08/04/22 revealed the dialysis registered dietician noted to encourage resident to eat meats and or eggs with each meal three times daily. There were multiple documentation entries from 02/01/22 to present to work with the facility to stabilize fluid intake and encourage high protein diet. One note, on 05/27/22 revealed the registered dietician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 22 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 called the nursing home to encourage a fluid restriction for the resident due to him being a dialysis patient. Level of Harm - Minimal harm or potential for actual harm Review of Resident #11's current orders for 10/2022 revealed the resident received hemodialysis every Monday, Wednesday, and Friday at 7:00 A.M. The resident had an order for a non-gastric irritating (no OJ, tomatoes or fried foods) regular texture diet with thin (regular) liquids. There was no evidence the resident was on fluid restriction or a renal diet. Residents Affected - Few Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he was not aware of any fluid or diet restrictions at the facility. Interview on 10/06/22 at 10:47 AM with Registered Nurse (RN) #50 revealed Resident #11 was not on a fluid restriction or renal diet. Interview on 10/06/22 at 11:00 A.M., with Dietary Aide #8 revealed Resident #11 had been on a fluid restriction but it was discontinued a long time ago. Interview on 10/05/22 at 2:44 P.M., 10/06/22 11:50 A.M. and 10/11/22 at 10:25 A.M. with Dietician #80 revealed the resident's fluid restriction was not reordered upon his return from a hospital visit in December 2021. Dietician #80 revealed she was not aware of the dialysis dietician recommendation for diet and fluids until the surveyor had requested notes from the dialysis centers dietician during the survey. The resident was in and out of the hospital multiple times in the past year and his diet and fluid restriction orders were not reordered. The dietician reported she was able to write dietary orders, however the facility policies was she was not permitted to write orders. She had not talked to the dialysis dietician probably since spring regarding this resident. Dietician #80 revealed she was not aware the dietician from the dialysis center had called the facility in May 2022 to discuss the resident's fluid restrictions. Dietician #80 revealed she called and spoke to the dialysis dietician on 10/06/22 after reviewing the notes and verified orders for a 1500 cubic centimeter (cc) fluid restriction, however she did not verify the diet order for the resident. The dietician currently reported the resident's diet order was for GI issues and not his renal failure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 23 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review, facility policy and procedure review and interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 42 residents residing in the facility. Findings include: Review of the facility assessment, dated 02/02/22 revealed no evidence of RN requirements, however the assessment revealed nursing was available 24 hours a day. Review of the staffing schedule, daily posting, and timecards dated 08/29/22 to 09/25/22 revealed there was no consecutive RN coverage for eight hours as required on 09/03/2, 09/10/22, or 09/11/22. Interview on 10/05/22 at 9:23 A.M. with Human Resource (HR)/Scheduler #42 verified there was only six hours RN coverage on 09/03/22 and there was no RN coverage on 09/10/22 or 09/11/22 due to call offs and no RNs to cover the shifts. Interview on 10/05/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed there was not eight hours of consecutive RN coverage on 09/03/22, 09/10/22, or 09/11/22. Review of the Staffing policy, dated 2017 revealed the facility would provide enough staff with the skills and competency necessary to provide care services for all residents in accordance with resident care plans and the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 24 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure parameters were noted when to administer analgesic verses narcotic pain medication. The facility also failed to ensure nonpharmacological intervention were attempted prior to administration of narcotics. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including renal dialysis, osteoarthritis of the knee, and unspecified pain. Review of Resident #11's orders, dated 09/01/22 to 10/06/22 revealed the resident was ordered Acetaminophen 325 milligrams (mg) two tablets every four hours as needed for pain and Oxycodone 10 mg one tablet every six hours as needed for pain. Review of Resident #11's medication administration records (MAR) dated 09/2022 and 10/2022 revealed Acetaminophen was administered for a pain level of four to six as well as Oxycodone being administered for pain rated a level of zero to nine. Review of Resident #11's progress notes dated 09/01/22 to 10/06/22 revealed resident received 35 doses of Oxycodone without evidence a nonpharmacological interventions being considered or attempted first. Interview on 10/06/22 at 10:17 A.M. with the Director of Nursing (DON) confirmed there were no parameters as to when staff were to administer the Acetaminophen versus Oxycodone for the same pain level. The DON also verified there were several times nonpharmacological interventions were not attempted prior to administering the as need narcotic medication. The DON reported nurses should try a nonpharmacological intervention prior to administering Oxycodone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 25 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, facility policy and procedure review and interview the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed psychotropic medications. This affected one resident (#21) of five residents reviewed for unnecessary medications use. Findings include: Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including depression, Alzheimer's Disease and schizoaffective disorder. The diagnosis of Parkinson's Disease was added to the resident's medical record in December of 2021. Review of the resident uses anti-anxiety medications related to anxiety disorder plan of care, dated 07/07/21 revealed interventions including administer medications per orders and observe for side effects and effectiveness. Review of the physician's orders revealed an order for Vistaril (anti-anxiety medication) 50 milligrams tablet one tablet by mouth twice a day for anxiety disorder (initiated 07/24/22) and one 50 mg tablet daily as needed for restlessness for 14 days only (dated 09/23/22) and discontinued on 10/07/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months. Review of the Medication Administration Record (MAR) for September 2022 revealed the resident received as needed Vistaril on 09/24/22 at 2:17 P.M., 09/25/22 at 3:43 P.M. and 09/27/22 at 10:00 P.M. All doses were marked as effective. Review of the nursing progress notes revealed the following: On 09/25/22 at 3:41 P.M. the resident continued to wander around the facility in his wheelchair looking for family, tried to transfer self and appeared anxious. As needed Vistaril given. On 09/25/22 at 4:06 P.M. the resident's fingernails were cleaned and trimmed. On 09/27/22 at 10:36 P.M. no adverse reactions from increase to Vistaril. Received one dose this shift for insomnia/agitation. Further review of the medical record revealed no evidence non-pharmacological interventions were attempted prior to administration of the Vistaril on 09/25/22 and 09/27/22. On 10/06/22 at 2:00 P.M. interview with the Director of Nursing verified non-pharmacological interventions were not attempted prior to the administration of the as needed Vistaril. The DON stated the interventions attempted should be documented in the medical record and the progress notes should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 26 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete contain documentation describing the resident's behaviors that warrant the use of the as needed medication. The DON verified the care plan did not inform the staff to attempt non-pharmacological interventions or the specific interventions to try for the resident prior to administering the as needed medication. Review of an untitled policy, dated 04/24/18 revealed when giving as needed medications the following steps would be completed including attempt non-pharmacological interventions prior to giving the medication and document in the progress notes what non-pharmacological interventions were attempted. Give as needed medication if non-pharmacological interventions were not effective. Event ID: Facility ID: 366416 If continuation sheet Page 27 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, infection control log review, McGeer's Criteria review, facility policy and procedure review and interview the facility failed to ensure antibiotic use was appropriate and/or met antibiotic stewardship criteria. This affected two residents (#3 and #21) of five residents reviewed for unnecessary medications and one resident (#40) of one resident reviewed for antibiotic stewardship. Residents Affected - Few Findings include: 1. Review of Resident #3's medical record revealed an admission date of 05/30/19 with diagnoses including overactive bladder, dementia and constipation. Review of the June 2022 Infection Control Log revealed a urine culture was obtained due to increased behaviors and urgency on 06/17/22 and contained greater than 100,000 colony count of escherichia coli and this met McGeer's Criteria for treatment due to the colony count and increased urgency. The resident was treated with the antibiotic, Keflex for a urinary tract infection. Review of the urine culture obtained on 06/17/22 and verified on 06/19/22 revealed the resident did have E coli in her urine, however Keflex was not listed as a treatment option. Review of the physician's orders revealed Keflex 500 milligrams twice a day for seven days was ordered on 06/17/22 and initiated on 06/18/22. The resident received the entire course of antibiotics. Review of the nursing progress note, dated 06/17/22 at 3:20 P.M. revealed the resident was transported to the emergency room due to suicidal ideations. The resident returned to the facility at 9:01 P.M. with orders for Keflex 500 mg twice a day for seven days to treat a urinary tract infection. Further review revealed on 06/20/22 at 9:17 P.M. revealed the urinalysis and culture was received and showed greater than 100,000 E. coli. The nurse practitioner was notified and ordered to continue Keflex as ordered from the emergency room. On 10/11/22 at 3:55 P.M. interview with the Director of Nursing (DON) verified the resident met criteria for treatment of a urinary tract infection, however the antibiotic used was not indicated for treatment of the organism the resident had in her urine. The DON verified the facility utilized McGeer's Criteria for the definition of infections and antibiotic stewardship. 2. Review of Resident #21's medical record revealed an admission date of 04/08/20 with diagnoses including Alzheimer's Disease, acute respiratory failure with hypoxia and hypotension. Review of the June 2022 Infection Control Log revealed Resident #21 presented with a cough and hoarseness on 06/24/22 and a chest x-ray was obtained. The resident's chest x-ray was negative for acute cardiopulmonary disease but due to the resident having two symptoms, the resident met McGeer's criteria for treatment of an upper respiratory infection. The resident received Zithromax 500 mg the first day and 250 mg three days following the loading dose beginning 06/24/22. Review of the physician's orders revealed Zithromax 500 mg the first day and 250 mg each day following for three days, dated 06/24/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 28 of 29 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Vista Royale LLC 1800 Sinclair Avenue Steubenville, OH 43953 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes, from 06/24/22 through 06/28/22 revealed the resident had a non-productive cough but no other symptoms were documented. Review of the McGeer's Criteria revealed the resident must present with at least two symptoms to meet criteria for treatment. Residents Affected - Few On 10/11/22 at 3:58 P.M. interview with the DON verified the medical record only indicated the resident had a non-productive cough with no other symptoms were documented. The DON verified the resident did not meet criteria for treatment of an upper respiratory infection due to lack of symptoms present. 3. Review of Resident #40's medical record revealed an admission date of 10/11/21 with diagnoses including Alzheimer's Disease, mild chronic kidney disease and hypertension. Review of the July 2022 Infection Control Log revealed the resident had increased falls and a urinalysis was completed on 07/21/22. The urinalysis did not contain abnormalities to require a urine culture. The resident did not meet McGeer's Criteria for treatment due to not meeting criteria for a urine culture. However, the resident was ordered the antibiotic, Keflex and received the entire course of treatment. Review of the nursing progress note, dated 07/21/22 at 6:41 P.M. revealed the resident was sent to the emergency room due to somnolence, increased falls and disequilibrium. The resident returned with orders for antibiotic, Keflex 500 mg every six hours for UTI for seven days. Review of the physician's orders, dated 07/22/22 revealed orders for Keflex 500 mg every six hours for seven days. Review of the July 2022 MAR revealed the resident received the Keflex from 07/22/22 through 07/29/22. Review of the nursing progress notes revealed the facility received the urinalysis results on 07/25/22 and reported the results to the physician with orders to continue Keflex as ordered in the emergency room. On 10/11/22 at 4:00 P.M. interview with the DON verified the resident's urinalysis did not indicate the resident had a UTI and therefore did not meet McGeer's Criteria for treatment. The DON verified the resident was treated with Keflex without appropriate justification and the physician did not provide rationale as to why treatment should continue. Review of the Infection Prevention and Control: Antibiotic Stewardship Policy, dated 02/20/20 revealed the facility had developed and implemented written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practices based on recognized guidelines were incorporated in the residents' care policies and procedures. Nursing would obtain labs, cultures, chest x-rays etc as ordered and fax or call results to the physician. Nursing would follow orders as given by the physician, nursing would complete the criteria checklist as related to symptoms, educate nursing staff on what to monitor of criteria if not met and continue to inform the physician when criteria not met for antibiotic stewardship protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366416 If continuation sheet Page 29 of 29