Vista Center of Boardman: COVID PPE Failures - OH
The aide, identified in inspection records only as Medication Aide #380, told inspectors she had put on a face shield at first but took it off. It was too hot.
Federal inspectors documented the sequence on the morning of August 18, 2025, at 8:46 a.m. What they observed was specific: the aide exiting the room of Resident #35, who had tested positive for COVID-19 and was under droplet isolation protocols, wearing an N-95 mask stacked on top of a surgical mask. The N-95 sat below her nose. The surgical mask covered it. She had worn neither gloves nor a gown inside the room. She had not removed or discarded the masks before moving into shared spaces.
Four minutes later, at 8:50 a.m., inspectors interviewed her. Medication Aide #380 confirmed that masks were supposed to come off and be discarded when leaving an isolation room. She confirmed she had not worn gloves or a gown while helping Resident #35 eat breakfast. On the question of the gown, she said she didn't think one was needed, pointing to a sign posted outside the door that listed only a mask and face covering as requirements.
There was a sign. It was wrong, or at least incomplete.
The facility's own Regional Quality Assurance Nurse, interviewed that same afternoon, confirmed that the correct protective equipment for staff assisting a COVID-positive resident with meals included a gown, gloves, a mask, and eye protection. The N-95, she added, should be removed before leaving the room. Not repositioned. Removed.
Resident #35's condition that morning was not abstract. A nursing progress note entered at 10:47 a.m. on August 18 recorded a temperature of 102.4 degrees Fahrenheit, a pulse of 102 beats per minute, poor intake of food, drink, and medications, and an altered mental status. By the time that note was written, the decision had already been made: Resident #35 would be transferred to the hospital.
The administrator, interviewed at 1:40 p.m. that day, acknowledged the facility had no written policy on how staff should put on or take off protective equipment. The facility followed CDC guidelines, the administrator said. The CDC guidance reviewed by inspectors, dated June 24, 2024, called for a NIOSH-approved N-95 respirator or higher, a gown, gloves, and eye protection covering the front and sides of the face.
None of those four items were fully in place when Medication Aide #380 helped a feverish, cognitively altered, COVID-positive resident eat breakfast.
A registered nurse, RN #371, told inspectors that staff entering Resident #35's room were required to wear gloves, a face shield, and an N-95 before entering, and that a gown was required for any direct personal care. Helping someone eat is direct personal care. The RN also said, during the same interview, that a gown was "typically not needed" for droplet isolation unless close contact was required, which suggests the facility's own clinical staff were not operating from a consistent understanding of what the protocols demanded.
The sign on the door listed a mask and a face covering. The aide read the sign and followed it. The sign was not enough.
Inspectors noted the PPE failure as an incidental finding, identified during a separate complaint investigation. The violation was classified at the minimal harm level. Resident #35, running a fever above 102 and no longer eating or drinking reliably, had already been sent to the hospital by the time that classification was assigned.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
VISTA CENTER OF BOARDMAN in BOARDMAN, OH was cited for violations during a health inspection on August 20, 2025.
The aide, identified in inspection records only as Medication Aide #380, told inspectors she had put on a face shield at first but took it off.
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.