Vista Center Of Boardman
VISTA CENTER OF BOARDMAN in BOARDMAN, OH — inspection on August 20, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the interview, Regional QA Nurse #320 confirmed she updated the care plan on
regressed to a Stage IV as of 07/24/25 and Regional QA Nurse #320 confirmed the care plan would
working on the date the new treatment orders were obtained (06/12/25) discovered and reported an open area on the coccyx of Resident #41.
During this interview, LPN #357 confirmed the wound was probably the size of a dime with some slough noted, appearing to be an unstageable pressure ulcer.
LPN #357 further confirmed an order was obtained from the nurse practitioner and a calcium alginate and foam dressing were applied per orders.
During the interview, LPN #357 verbalized a lack of knowledge related to initiating a Skin Grid Pressure 3.0 - V 2 assessment when a new pressure area was identified and confirmed a progress note detailing the new skin concerns must not have been created.
Review of the telephone message recorded on 08/19/25 at 5:26 P.M. revealed Wound APRN #325 confirmed that on 07/24/25, the wound care orders for Resident #41 reflected an increase in frequency and were to be performed every shift (twice daily) and that ordered frequency had not been changed since 07/24/25.
Review of the undated policy titled Dressing Change - Clean revealed wound care protocol was to clean the bedside stand and establish a clean field prior to wound care.
The policy further revealed the process was to perform hand hygiene, apply clean gloves, remove the soiled dressing and discard into the nearby plastic or biohazard bag, perform hand hygiene, open the clean, dry dressing by pulling only the exterior corners outward and only touching the exterior surface of the packaging, open all needed dressing supply products, put on clean gloves, cleanse the wound per orders, apply ordered treatment, remove and discard gloves, wash hands thoroughly, reposition the resident, then perform hand hygiene again.
The policy did not mention the practice of double-gloving.
Review of the updated policy titled Pressure Ulcer Prevention Intervention revealed residents at risk for pressure ulcers were to be kept clean and dry, avoid sheering and friction, be provided a gel cushion (or equivalent) for sitting, and be repositioned every two hours to relieve or redistribute pressure.
Review of the policy further revealed a specialty mattress, which included a low air loss or alternating mattress was to be used for Stage III and Stage IV pressure ulcers, and a Clinitron or comparable specialty mattress was to be used for an unstageable pressure ulcer or a complicated Stage IV pressure ulcer.
The policy further revealed a high-protein nutritional supplement should be added for residents at risk for pressure ulcers.
This deficiency represents non-compliance investigated under Complaint Number 2570357.
365760 08/20/2025
Vista Center of Boardman 830 Boardman Canfield Rd Boardman, OH 44512
Observation on 08/18/25 at 8:46 A.M. revealed Medication Aide #380 exited the room of Resident #35 wearing the N-95 on top of a surgical mask, with the N-95 positioned under her nose (the surgical mask was over the nose) and then clearing a meal tray from the dining room and another resident's room.
Interview with Medication Aide #380 at 8:50 A.M. confirmed masks were to be removed and discarded upon exiting rooms with droplet isolation and replaced as necessary.
Medication Aide #380 further confirmed no gown, gloves, or face shield were used to assist Resident #35 with breakfast, adding that a face shield was initially put on, but taken off because it was too hot.
During the interview, Medication Aide #380 denied the need to gown to enter the room of a COVID-19 positive resident, confirming there was a sign outside the door only indicating a mask and face covering was needed. A nursing progress note dated 08/18/25 at 10:47 A.M. revealed Resident #35 had a temperature of 102.4 degrees Fahrenheit (F), a pulse of 102 beats per minute, poor oral intake of foods, drinks, and medications, and an altered mental status.
The note further revealed Resident #35 was to be transferred to the hospital.
Interview on 08/18/25 at 1:40 P.M. with the Administrator confirmed there was no facility policy on donning and doffing PPE, but the facility followed CDC guidelines.
Interview on 08/18/25 at 2:48 P.M. with Regional Quality Assurance (QA) Nurse #320 confirmed the appropriate PPE required for staff to assist a COVID-19 positive resident with meals included a gown, gloves, mask, and eye protection and that the N95 mask should be removed when leaving the resident's room.
Review of the Centers for Disease Control and Prevention (CDC) on-line guidance for use of personal protective equipment (PPE) for care of persons with COVID-19 positive infection dated 06/24/24 revealed health care workers should use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection, such as goggles or a face shield, that covered the front and sides of the face.
This deficiency was an incidental finding identified during the complaint investigation.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.