Villa Vista Royale LLC

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to update a resident's Pre-admission Screening and Resident Review (PASARR) with changes to the resident medical diagnosis This deficient practice affected one resident (Resident #5) of one resident reviewed for PASARR. The facility census was 46. Findings Include: Review of Resident #5's medical record revealed an admission date of 07/01/24 with diagnoses including but not limited to high blood pressure, anxiety disorder, post traumatic stress disorder (PTSD), and history of falls. Review of Resident #5's physician orders revealed an order dated 04/01/25 for the antidepressant medication, Zoloft Oral Tablet 50 milligrams (mg). [...]

Inspectors wroteBased on record review, observation, interview, review of manufacturer operating guidelines, and facility policy review the facility failed to ensure pressure relieving interventions were appropriate based on resident weight and the location of the resident's pressure ulcer was accurately documented. This affected one resident (Resident #24) of two residents reviewed for pressure ulcers. The facility census was 46. Findings Include: Review of Resident #24's medical record revealed an admission date of 04/28/23 with diagnoses including but not limited to dysphagia, dementia, hypokalemia, depression disorder, and high blood pressure. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #31 was provided a dignified dining experience. This affected one resident (#31) of thirteen residents observed for dining.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.