Vista Center of Boardman: Pressure Ulcer Care Failures - OH
The resident, identified in inspection records as Resident #41, was at the center of a complaint investigation completed August 20 at Vista Center of Boardman, a nursing facility on Boardman Canfield Road. By the time inspectors finished their review, the wound had progressed to a Stage IV pressure ulcer, the most severe classification, with bone, tendon, or muscle potentially exposed. It had started, according to a nurse interviewed during the investigation, roughly the size of a dime.
On June 12, 2025, a nursing aide found and reported an open area on the coccyx of Resident #41. LPN #357, reached by phone on August 18, confirmed the wound was small, showed some slough, and appeared unstageable at that point. An order was obtained from a nurse practitioner, and a calcium alginate and foam dressing were applied. That part worked. What came next didn't.
LPN #357 told inspectors she didn't know she was supposed to initiate a Skin Grid Pressure 3.0 assessment when a new pressure area was identified. She also confirmed that a progress note documenting the new skin concern was never written. The assessment wasn't completed. The note didn't exist. The care plan wasn't updated.
The care plan, as of mid-August, still described Resident #41's condition as a Stage II pressure ulcer. That was already wrong before inspectors arrived. Regional QA Nurse #320 updated it on August 14 to reflect actual altered skin integrity, but even that correction was outdated almost immediately. During the inspection interview, Regional QA Nurse #320 learned for the first time that the wound had already progressed to Stage IV as of July 24, more than three weeks earlier. She confirmed the care plan would need to be updated again.
The wound had been Stage IV for nearly a month before the care plan reflected anything close to reality.
A separate piece of the record pointed to another gap. Wound APRN #325, reached by phone on August 19, confirmed that wound care orders were changed on July 24 to increase treatment frequency to every shift, meaning twice daily. Those orders had not been changed since. The orders themselves were current. But the care plan guiding the broader approach to Resident #41's care remained a document describing a different wound in a different patient.
The facility's own dressing change policy laid out a detailed sequence: clean the bedside stand, establish a clean field, perform hand hygiene, remove the soiled dressing, perform hand hygiene again, open clean dressings by touching only the exterior corners, apply treatment, remove gloves, wash hands, reposition the resident, perform hand hygiene a final time. The policy said nothing about double-gloving, a detail inspectors noted in their review of what was and wasn't in writing.
The pressure ulcer prevention policy required residents at risk to be repositioned every two hours, kept clean and dry, and provided gel cushions for sitting. For Stage III and Stage IV ulcers, a specialty mattress, specifically a low air loss or alternating pressure mattress, was required. For unstageable or complicated Stage IV ulcers, a Clinitron or comparable mattress was called for. Whether Resident #41 had the right mattress at the right stages of the wound's progression is not addressed in the inspection record. What the record does show is that the care plan guiding staff decisions about this resident's care was wrong for weeks.
The inspection was triggered by a complaint, filed under Complaint Number 2570357. CMS classified the harm level as minimal harm or potential for actual harm, affecting a few residents. That classification reflects the regulatory framework's language, not necessarily the experience of someone whose wound moved from unstageable to Stage IV over the course of a summer.
LPN #357 described her gap in knowledge plainly: she didn't know the assessment was required. She said it, on the record, to inspectors. That kind of candor is not common in these reports. It also doesn't change what happened to Resident #41, whose wound reached its worst possible stage while the paperwork described something else entirely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vista Center of Boardman from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
VISTA CENTER OF BOARDMAN in BOARDMAN, OH was cited for violations during a health inspection on August 20, 2025.
It had started, according to a nurse interviewed during the investigation, roughly the size of a dime.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.