Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, record review, and policy review the facility failed to assess and monitor a
resident's edema while having a sling and brace in place for a humerus fracture. This affected one resident
(#249) of 24 resident records reviewed for assessments.
Residents Affected - Few
Findings include:
Review of record revealed Resident #249 was admitted to the facility on [DATE] with diagnoses including
left humerus fracture, hypertension (HTN) atrial fibrillation, generalize anxiety disorder, major depressive
disorder, Gastrointestinal reflux disease (GERD), type 2 diabetes, heart failure, cerebrovascular disease,
hyperlipidemia, anemia, mitral stenosis, lymphedema, atherosclerotic heart disease, abnormal weight loss,
Transient ischemic attack (TIA), breast cancer, hypothyroid, dry eyes, cataracts, polyarthritis, hyponatremia,
diverticulitis left breast lumpectomy with lymph node sampling, lumpectomy of right breast.
Review of baseline care plan completed 03/25/25 revealed Resident #249 required two assist with
ambulation and transfers, one assist with bathing and hygiene, and a one assist with dressing and
grooming. Resident #249 needed assistance with setup for meals, two assist for toileting, and used a wheel
chair. Goals included observing pain and report as indicated, administer pain medication as ordered, and
attempt non-medication interventions. Resident is able to communicate wants and needs. Visual ability
indicates Resident #249 used glasses and will have adequate vision. Resident was alert to person, place,
and time. Resident has anxiety and depression and will have a safe comfortable environment, social
service visit and encouraged to ventilate feelings, provide redirection for episode behavior, monitor for
medication effectiveness and side effects, and provide emotional support. Consult physical therapy (PT)
and occupational therapy (OT) as ordered, evaluate for unsteady gate, ambulation devices as necessary,
call bell within reach, observe footwear and non-skid socks. Prevent pressure ulcer and skin break down by
following facility skin protocol, turn and position PRN, weekly skin evaluation, report any redness to medical
director (MD), keep linens dry and wrinkle free, do prescribed treatment as ordered, notify MD is treatment
is ineffective.
Record review of Emergency department physician notes dated 03/23/25 revealed Resident #249 arrived
from home due to a fall from ground level from standing position onto her left side, states she has left
shoulder pain. Left arm x-ray revealed an acute humerus fracture. Left humeral sugar-tong splint placed to
left humerus for stabilization.
Record review of progress notes revealed a note on 03/25/25 at 6:00 P.M. by Licensed Practical Nurse
(LPN) that identified Resident #249 had a brace and sling to left upper extremity (LUE) with pitting +2
edema to left hand. States brace/ sling can be removed for care. Resident is in good spirits
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
366416
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
04/03/2025
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 0684
with pain upon movements.
Level of Harm - Minimal harm
or potential for actual harm
Record Review of a comprehensive nursing note written on 03/26/25 by Registered Nurse (RN) #123 at
5:47 P.M. revealed nonpitting edema to LUE due to lymphedema. Sling in place per order to LUE.
Residents Affected - Few
Record review of comprehensive nursing notes revealed no documentation of Resident #249's edema to
the LUE on comprehensive nursing notes completed on 03/25/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25,
03/31/25, 04/01/25, and 04/02/25.
Record review revealed no documentation of monitoring or evaluation of Resident #249's LUE edema.
Record review revealed no documentation of interventions ordered or being implemented for Resident #249
LUE edema.
Observation on 03/31/25 at 11:10 A.M. revealed Resident #249's arm in a brace and sling, only able to
visualize Resident #249's hand with swelling to the left hand.
Observation on 4/01/25 at 11:21 A.M. revealed Resident #249 moving herself down the hallway in her
wheelchair with a brace and sling applied to the LUE. Unable to visualize LUE from the wrist up. Swelling
noted to the left hand of Resident #249.
Observation on 04/02/25 at 9:05 A.M. revealed Resident #249 and RN #123 speaking. Observed sling and
brace to Resident #249's LUE. Unable to visualize Resident #249's LUE from wrist up. Resident #249 had
swelling to the left hand.
Interview on 04/02/25 at 10:26 A.M. with Registered Nurse (RN) #123 revealed that Resident #249's arm
had been swollen due to her lymphedema and was swollen on previous admissions. RN#123 stated before
they were able to elevate her arm, but therapy has Resident #249 limited on what she can do with her left
arm and they are only able to take the brace off for care. RN #123 stated the edema should be documented
in the comprehensive nursing assessment.
Interview on 04/02/25 at 10:13 A.M. with Occupational Therapy Assistant (OTA) #555 revealed Resident
#249 is coming to therapy 3-5 times a week, they've had a few sessions and are working on exercises
Resident #249 can do while seated, improving range of motioning to her left upper extremity, and hand
exercises to help with the edema in that arm.
Interview with RN #111 on 04/02/25 at 2:20 P.M. stated that the edema on the arm should be documented.
RN #111 stated she understands it is necessary to evaluate the swelling to monitor for any changes
especially with the sling and the fracture to the extremity.
Review of policy Charting and Documentation (revised July 2017) revealed treatments or services
performed must be documented in the medical record, documentation will be objective (not opinionated or
speculative), complete, and accurate. Documentation will include care specific details including the
assessment data and any unusual findings obtained during the procedure/treatment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 2 of 8
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
04/03/2025
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
medical record review, observation, restorative master log, review of the therapy log, and interview the
facility failed to ensure a newly admitted resident was accurately assessed for range of motion (ROM) and
failed to ensure an individualized restorative program was implemented to ensure the resident maintained
range of motion. This affected one resident (#399) of three reviewed for ROM.
Findings included:
Medical record review revealed Resident #399 was transferred to the facility on [DATE] from another skilled
nursing facility located in another state. The resident diagnoses included stiffness of unspecified joint,
absence of right leg above knee, diabetes type two, hemiplegia and hemiparesis following cerebral
infarction affecting right dominating side, lack of coordination, weakness, and difficulty walking.
Review of Resident #399's base line care plan dated 03/01/25 revealed the resident's bilateral hands the
fingers (last two) only opened 50-75%. There were no goals or interventions documented.
Review of Resident #399's comprehensive plan of care revealed no evidence of a plan of care for limited
ROM/contractures.
Review of admission Minimum Data Set (MDS) dated [DATE] revealed the resident had no impairment of
the upper extremity and impairment one side of the lower extremity.
Review of Resident #399's mobility evaluation dated 03/07/25 revealed the resident had full range of motion
of right and left fingers.
Review of Resident #399's orders and task (CNA documentation) revealed no evidence the resident had
orders for splints, braces, or restorative therapy.
Review of restorative master log sheet dated 04/2025 revealed no evidence Resident #399 was receiving
restorative services.
Review of the Therapy log dated 04/2025 revealed no evidence Resident #399 was receiving therapy
services.
Interview and observation with Resident #399 on 03/31/25 at 10:29 A.M. and 04/01/25 at 8:25 A.M.,
revealed the resident had contractures noted right pinky and left ring finger and pinky. The resident
confirmed he had not received therapy, splints, or any type of treatment to prevent contractors in his fingers
from getting worse since he had been admitted to the facility a month ago. The resident reported he was in
a skilled nursing home in another state and was not receiving good care which resulted in his fingers being
contracted. The resident reported he was hoping to have therapy and they would put something in place but
he has not seen therapy yet.
Interview and observation on 04/01/25 at 1:25 P.M. of Resident #399 with Licensed Practical Nurse (LPN)
#110 and Certified Nursing Assistant (CNA) #148 confirmed Resident #399's right pinky and left ring finger
and pinky were contracted. The LPN attempted to straighten out the resident fingers,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 3 of 8
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
04/03/2025
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
however, was not able due to the extent of the contractures and the resident was experiencing pain. The
LPN was not able to open fingers more than halfway on the right and less than halfway one the left. The
CNA (who was related to Resident #399) and resident confirmed the contractures had not worsened in the
last 30 days.
Interview on 04/01/25 at 1:42 P.M., with LPN/Restorative Nurse #300 confirmed Resident #399's admission
MDS and mobility evaluation were inaccurate due to the resident having limited ROM/contracture with his
fingers on admission per the baseline plan of care and resident interview. The LPN confirmed the resident
did not have a comprehensive plan of care for the limited range of motion/contractors nor was in a
restorative program/therapy initiated, however a program should have been initiated. LPN #300 confirmed
the resident was not receiving therapy services.
Review of Resident #399's MDS note dated 04/01/25 (after surveyor confirming findings with staff) revealed
the resident stated he would enjoy having exercise to his joints. The resident stated his ROM had not
declined since admission. The resident had noted limitation to his pink finger on the right hand and last two
fingers on the left hand. The resident reported the limitation happened at the place he was prior to coming
to the facility. Will add ROM program.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 4 of 8
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
04/03/2025
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, staff interview and policy review, the facility failed to identify, monitor and measure
targeted behaviors with the use of antipsychotic medication. This affected one resident (#14) of five
residents reviewed for unnecessary medication. The facility census was 50 residents.
Findings include:
Review of Resident #14's medical record revealed a 08/21/23 admission with diagnoses including severe
protein calorie malnutrition, magnesium deficiency, hypo-osmolality an hyponatremia, age related physical
disability, pain, lack of coordination, muscle wasting and atrophy, peripheral vascular disease, Vitamin D
deficiency, neuropathy, bipolar disorder, major depressive disorder, Vitamin B 12 deficiency anemia,
dizziness and giddiness, gastroesophageal reflux disease, insomnia, dysphagia, anxiety disorder,
hypokalemia, hypothyroidism, hypertension, orthostatic hypotension, and diverticulosis,
Review of the Quarterly 01/02/25 Minimum Data Set assessment revealed the resident was independent
for daily decision making with little interest or pleasure in doing things, feeling down, depressed, or
hopeless. The resident was feeling tired or having little energy, having trouble falling or staying asleep, or
sleeping too much, She had a poor appetite. She had trouble concentrating on things, such as reading the
newspaper or watching television. She was on antipsychotics, antianxiety, opioid, antiplatelet, and
anticonvulsant mediations. She had not started on hospice yet.
A review of physician orders included Ativan, antianxiety medication, 0.5 milligram (mg) tablet TID, three
times a day for anxiety ordered 08/24/23. Remeron, an antidepressant, 15 mg daily for major depressive
disorder since 01/23/24. Lamictal, an antipsychotic, 150 mg tablet at bedtime for bipolar disorder current
episode manic severe with psychosis, Risperdal 1 mg daily ordered 06/07/22. Abilify, an antidepressant, 5
mg at bedtime was ordered 08/28/24 for depression.
Review of the 06/06/19 psychotropic drug care plans included an anti-depressant plan of care revealed the
resident would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad
mood. The goal was the resident will be free of signs and symptoms of depression, anxiety or sad mood.
The plan did not identify what behaviors the resident exhibited while depressed. There were no behaviors
identified to monitor for the use of antidepressants.
Review of the 11/03/22 plan of care for psychotropic drug use included the resident was at risk for adverse
consequences related to receive an antipsychotic medication for psychosis. The long-term goal was the
resident will not exhibit signs and drug related side effects or adverse drug reaction. The plan did not
identify what behaviors the resident exhibited while psychotic. There were no behaviors identified to monitor
for the use of antidepressants.
Review of the Certified Nurse Aide TASK documentation revealed there was not a behavior section
included in their documentation.
Review of the Medication Administration Record (MAR) and the Treatment Record (TAR) revealed there
were no sections related to the documentation of targeted behaviors for the use of psychotropic medication.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 5 of 8
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
04/03/2025
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
Interview on 04/01/25 on 11:59 A.M. with the Director of Nursing verified the resident had no identified
targeted behaviors being monitored and measured for the use of psychotropic medications. Further verified
behavior monitoring would assist with the justification to increase or titrate medications.
Review of the facility 08/30/24 Psychotropic Medication policy included if behaviors are displayed to
document the behaviors in the Nurse Notes and interventions used.
Event ID:
Facility ID:
366416
If continuation sheet
Page 6 of 8
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
04/03/2025
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 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the
results.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, interview, and policy review the facility failed to ensure laboratory testing was
completed per physician order. This affected one resident (#28) of five residents reviewed for medication
review.
Findings included:
Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses
including history of hypertension, grade I diastolic dysfunction, and dementia.
Review of Resident #28's orders dated 03/2025 revealed on 10/28/22 the physician ordered lipid profile to
be obtained every six months (April/October).
Review of laboratory results dated [DATE] to 04/01/25 revealed no evidence a lipid profile was obtained per
orders in October 2024.
Further review of laboratory results revealed the last lipid profile was obtained on 04/05/24. The resident's
cholesterol was 250 (high) (normal less than 200 milligram (mg) / deciliters (dL), triglyceride 234 high
(normal less 150 mg/dl), HDL 36.0 low (higher than desirable 40 mg/dl), LDL 167 high (less than 100 if
desirable if clinical atherosclerotic disease or diabetes had been diagnosed).
Review of the facility policy titled Lab Draw dated 01/2025 revealed labs would be drawn as ordered by the
physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 7 of 8
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
04/03/2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, policy review and staff interview the facility failed to ensure residents had
appropriate indications for use of antibiotics. This affected one resident (#20) of five residents reviewed for
antibiotic use. The facility census was 50.
Residents Affected - Few
Findings include:
Review of Resident #20's medical record revealed an admission date of 12/13/22 with diagnoses that
included diabetes mellitus, hypertension and peripheral vascular disease.
Review of Resident #20's nursing notes revealed on 11/01/24 the resident sustained a fall and was sent to
the local emergency department for evaluation. Upon return to the facility on [DATE], Resident #20 was
diagnosed at the emergency department with a urinary tract infection (UTI) and prescribed Cephalexin
(antibiotic) 500 milligrams (mg) every six hours for five days due to a UTI. Nursing staff advised Resident
#20's physician of the returning diagnosis and antibiotic order. Nursing staff also advised the physician the
resident's urinalysis was negative and resident asymptomatic for a UTI. Resident #20's physician advised
staff to continue the antibiotic. On 11/04/24, after receiving the final urinalysis results, the physician was
notified Resident #20 did not meet criteria and advised to continue the antibiotic as ordered.
Review of the physician's medication orders revealed on 11/02/24 Resident #20 was prescribed the use of
Cephalexin (antibiotic) 500 milligrams (mg) every six hours for five days due to a urinary tract infection
(UTI).
Review of the antibiotic assessment completed on 11/02/24 revealed Resident #20 did not meet McGeer's
criteria for appropriate indication for antibiotic use. The assessment indicated Resident #20 had a urinalysis
and culture that final results returned on 11/03/24 which indicated a bacteria growth of proteus mirabilis of
>100,000 colonies per million (cfu/ml). The resident had no additional symptoms of a UTI.
Review of facility policy titled Antibiotic Stewardship with a reviewed date of December 2016 revealed
antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic
stewardship program.
Additional policy review titled Infection Prevention and Control; Antibiotic Stewardship with a review date of
June 2024 revealed the facility administration and medical director should ensure that current standards of
practices based on recognized guidelines are incorporated in the residents care policies and procedures.
Interview with the Director of Nursing on 04/02/25 at 2:25 P.M. verified the antibiotic for Resident #20 on
11/02/25 did not meet criteria for appropriate indication for use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366416
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F688 - Mobility
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.
F758 - Medication Errors
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.
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
FAQ · About this visit
Common questions about this visit
What happened during the April 3, 2025 survey of VILLA VISTA ROYALE LLC?
This was a inspection survey of VILLA VISTA ROYALE LLC on April 3, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VILLA VISTA ROYALE LLC on April 3, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.