Vista Center of Boardman

Inspectors wroteBased on observation, interview, policy review and review of the microessentiallab.com website, the facility failed to have unexpired test strips to test for proper sanitization levels at the three-sink manual dish washing area. This had the potential to affect 45 residents receiving food from the facility kitchen. There was one (Resident #19) identified by the facility as receiving nothing by mouth. The facility census was 46.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to maintain a sanitary garbage storage area. This had the potential to affect all residents. The facility census was 46.

Inspectors wroteBased on record review, observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to maintain a clean and sanitary laundry environment to prevent the spread of germs, failed to ensure staff performed hand hygiene to prevent cross contamination of germs during medication administration for Resident #33 and Resident #21, failed to properly clean the glucometer after use to obtain Resident #39's blood sugar, failed to contain Resident #60's contaminated linen and personal protective equipment (PPE) appropriately and failed to provide Resident #1 with a sanitary area to eat his meal. [...]

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure proper grooming for Resident #53 related to removal of facial hair. This affected one (Resident #53) of three residents reviewed for activities of daily living. The facility census was 46.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to change nasal cannula tubing (a plastic tube with two prongs that goes into the nose to deliver oxygen) weekly for appropriate respiratory infection control. This affected one (Resident #1) of one resident reviewed for respiratory care and had the potential to affect 10 additional residents (2, #4, #13, #19, #21, #22, #23, #24, #30, and #38) identified by the facility as receiving oxygen therapy. The facility census was 46.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure medications were not left at the bedside for one resident (Resident #33) out of seven residents observed for medication administration. The facility census was 46.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure Resident #11's call light activation button was within reach to ensure it could be utilized. This affected one (Resident #11) of 46 residents screened for call light placement. The facility census was 46.

Inspectors wroteBased on record review, observation and interview, the facility failed ensure Resident #9's room was in good repair. This affected one (Resident #9) 46 during the initial screening and initial tour. The facility census was 46.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to provide interventions to prevent the development of an unstageable pressure ulcer, failed to timely and accurately document the initial assessment and weekly comprehensive assessments of the pressure ulcer, failed to timely coordinate ancillary wound care services to mitigate complications related to pressure ulcers, and failed to follow proper infection control procedures during wound care. This affected one (Resident #41) of two residents reviewed for pressure ulcers. The facility census was 51.

Inspectors wroteBased on observation, interview, medical record review, review of facility policy, and 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 (the novel coronavirus, also known as severe acute respiratory syndrome two or SARS-CoV-2), the facility failed to ensure the appropriate type of transmission-based precautions for Resident #41was identifiable to staff and visitors, failed to ensure proper infection control procedures were maintained during wound care for Resident #41, and failed to ensure appropriate precautions were maintained when providing care for Resident #35. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure there was a Registered Nurse (RN) present in the facility eight consecutive hours seven days a week. This had potential to affect all residents. The facility census was 47.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were reported to the state agency as required. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were thoroughly investigated. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests on the secured unit A. This affected 19 Residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) out of 47 residents observed for physical environment. The facility census was 47.

Inspectors wroteBased on observation, record review,interview, and facility policy review, the facility failed to ensure Resident #8 received timely incontinence care and failed to ensure Residents #8, #22, #46 and #47 received staff assistance for showering. This affected four residents (#8, #22, #46, and #47) of five residents reviewed for assistance with Activities of Daily Living (ADL) needs. The facility census was 43.

Inspectors wroteBased on interview, observation, record review and facility policy review, the facility failed to ensure effective infection control techniques were practiced during incontinence care. This affected one resident (Resident #8) out of five residents reviewed for infection control. The facility census was 43.

Inspectors wroteBased on observation, interview and review of facility documents and policy, the facility failed to provide therapeutic activities as scheduled and on weekends and evenings to meet the needs and preferences of the resident population. This had the potential to affect all 50 residents in the facility. The facility census was 50.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure a qualified activity director was overseeing the activity department to ensure therapeutic activities were being provided to the residents. This affected all 50 residents living in the facility. The facility census was 50.

Inspectors wroteBased on interview and record review the facility did not ensure each state tested nurse aide (STNA) received no less than twelve hours of annual in-service education. This had potential to affect all residents in the facility. The facility census was 50.

Inspectors wroteBased on record review and interview the facility did not ensure the dietary manager was qualified to oversee dietary service operations. This had the potential to affect all 50 residents receiving meals from the kitchen, as the facility did not identify any residents who did not eat by mouth (NPO). The facility census was 50.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure palatable food was served to the residents. This had the potential to effect 50 residents who received a meals from the facility kitchen. The facility identified there were no residents who did not eat by mouth (NPO). The facility census was 50.

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure food was stored in a manner to prevent contamination and/or food borne illness. The facility also did not ensure the kitchen was maintained in a sanitary manner. This had the potential to affect 50 residents. There were no residents identified by the facility as eating nothing by mouth (NPO). The facility census was 50.

Inspectors wroteBased on record review, review of the administrator job description and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident which included failure to ensure the Quality Assurance Performance Improvement (QAPI) committee meetings were held to include the medical director or designee and evidence of meetings as required were maintained, failure to ensure a qualified director of activities was employed in the facility and failure to ensure a therapeutic activities program was being developed and implemented for the residents. This had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure quarterly Quality Assurance Performance Improvement (QAPI)meetings were conducted and failed to have the designated medical director participate in the QAPI meetings. This had the potential to affect all residents. The facility census was 50.

Inspectors wroteBased on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, staff interview, and policy review , the facility failed to ensure enhanced barriers precautions (EBP) were followed for one resident (Resident #194) of nine residents who were identified by the facility as being on EBP (Residents #6, #12, #21, #26, #34, #35, #193, #194, and #196). The facility also failed to ensure annual tuberculosis (TB) signs and symptoms for employes were completed per the TB risk assessment and policy. This had the potential to affect all 50 residents in the facility. The facility census was 50.

Inspectors wroteBased on observation, interview and review of facility policy the facility did not ensure a safe, functional and comfortable environment for all residents. This had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on review of the resident funds accounts, review of the surety bond, interview, and review of the facility policy, the facility failed to provide a surety bond large enough to cover the total amount of money in all resident personal funds accounts. This had the potential to affect 20 residents identified as having resident fund accounts (Residents #3, # 4, #5, #7, #9, #10, #11, #12, #13, #20, #21, #23, #25, #26, #27, #31, #32, #33, #38, and #39). The facility census was 50.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure Resident #31's advance directives in the medical record and physician orders matched. The facility also failed to ensure the nurse had knowledge of which code status to follow. This affected one resident (#31) out of four residents reviewed for advance directives and had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on record review, interview, review of the Ohio Department of Health Gateway, and review of the facility abuse policy, the facility failed to report an allegation of resident-to-resident abuse within 24 hours to the state agency after Resident #38 threw a cup of hot coffee on Resident #144 . This affected one Resident (#144) out of one resident reviewed for abuse and had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure accurate care plans were in place for Residents #19 and #148. This affected two residents (#19 and #148) of four residents who were reviewed for care plans. This had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure timely and accurate care plans for Residents #34 and #35. This affected two residents (#34 and #35) of four residents who were reviewed for care plans. This had the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to provide oral care for Resident #194, who had hemiplegia and hemiparesis affecting the right dominant side and required supervision or touching assistance for oral hygiene. This affected one resident (#194) of one resident reviewed for activities of daily living (ADL) care and had the potential to affect all residents except seven residents (#4, #10, #12, #23, #32, #33, and #36) identified by the facility as independent with oral care. The facility census was 50.

Inspectors wrote3. A review of medical records for Resident #195 revealed an admission date of 10/01/24. Significant diagnoses included mixed simple and mucopurulent chronic bronchitis and heart failure. Significant orders included bumex (a water pill for fluid retention) 0.5 milligrams, give one tablet by mouth in the morning for fluid retention for seven days dated 10/07/24 and weekly weights times four weeks then monthly. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #195 was cognitively intact. A review of weights revealed on 10/02/24 Resident #195 weighed 174.5 pounds. On 10/03/24 Resident #195 weighed 201.6 pounds. There was no reweigh noted. On 10/08/24 Resident #195 weighed 187.0 pounds. There was no reweigh noted. On 10/15/24 Resident #195 weighed 185 pounds. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #15 received culturally competent trauma-informed care including the identification of triggers, and interventions to assist with the management to eliminate or mitigate re-traumatization of the resident. This affected one resident (#15) out of two residents reviewed for Post Traumatic Stress Disorder (PTSD). The facility census was 50.

Inspectors wrote2. A review of medical records for Resident #19 revealed an admission date of 04/10/23 with diagnoses including dementia in other diseases classified elsewhere unspecified severity with other behavioral disturbances, adult failure to thrive and other signs and symptoms involving cognitive function. Physician orders included Depakote sprinkles oral capsule delayed releases 125 milligrams (mg), give 125 mg two times daily for behaviors and 250 mg daily at bedtime for behaviors. There were no orders for depakote levels to be drawn. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had a moderate cognitive deficit. The MDS also revealed verbal behaviors occurring one to three days in the seven day look back period. [...]

Inspectors wroteBased on medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of the facility Abuse policy and interviews with staff, resident and family, the facility failed to ensure Resident #5, who was assessed to have severe cognitive impairment and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for psychosocial and physical harm on 03/12/24 at 3:17 P.M. for Resident #5, when Resident #42, who was cognitively intact, and had a known history of sexual behaviors towards other residents and staff prior to 03/12/24 and without planned interventions, was observed on her knees, naked from the waist down, performing oral sex on Resident #5. During an interview with Resident #5 he stated he would not be sexually interested in anyone but his wife. [...]

Inspectors wroteBased on medical record review, review of a Self-Reported incident and investigation, review of a soft file, review of resident council minutes, and interview, the facility failed to ensure sufficient staff to provide supervision and timely care. This had the potential to affect all 41 residents.

Inspectors wroteBased on review of resident council meeting minutes and interview, the facility failed to ensure resident concerns were addressed. This affected Residents #25, #29, #35, #36, #37, #38, #39, #46 and #47, residents of the B and C hall. The facility identified 25 residents who resided on the B and C halls. The facility census was 41.

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean and sanitary environment. This affected Residents #5, #8, #9, #10, #11, #12, #13, #14 and #15 whose rooms were randomly viewed for cleanliness. The census was 41.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of sexual abuse were reported to the State Survey agency. This affected two (Residents #15 and #43) of seven residents reviewed for abuse. The facility census was 41.

Inspectors wroteBased on medical record review and interview, the facility failed to revise a care plan to include and address sexually inappropriate behaviors. This affected one (Resident #15) of seven residents reviewed for abuse. The facility census was 41.

Inspectors wroteBased on medical record review and interview, the facility failed to address recommendations for deep vein thrombosis (DVT) prophylaxis with the attending physician or Nurse Practitioner (NP) for one (Resident #21) of three residents reviewed for implementation of consultant recommendations/orders. The facility census was 41.

Inspectors wroteBased on observation, medical record review, policy review, and interview, the facility failed to ensure oxygen was provided in accordance with physician orders. This affected one (Resident #39) of three residents reviewed for oxygen use. The facility census was 41.

Inspectors wroteBased on medical record review, review of a soft file, and interview the facility failed to maintain complete and accurate medical records. This affected three (Residents #21, #42, and #43) of 15 residents reviewed. The census was 41.

Inspectors wroteBased on observation and interview, the facility failed to ensure clean and sanitary condition of the ice machine located downstairs by the elevator which provided ice for resident consumption. This had the potential to affect all residents in the facility excluding Resident #12, #22 and #39 who the facility identified as receiving nothing by mouth. The facility census was 50.

Inspectors wroteBased on observation and interview, the facility failed to maintain effective pest control on the C-unit for Resident #5, #13, #15, #25, #29, #31, #44, #46 and #49 and failed to maintain effective pest control on the secured unit in common areas which had the potential to affect all 15 residents (#2, #6, #10, #11, #18, #19, #20, #25, #26, #33, #36, #40, #45, #48 and #51) residing on the secured unit. This affected 24 residents of 50 residents living in the facility. The facility census was 50.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to ensure food was labeled and dated appropriately. This had the potential to affect 46 residents who received meals from the kitchen. The facility identified two (Residents #13 and #250) who received nothing by mouth. The facility census was 48.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was given to two Residents (#255 and #256) upon discontinuation of skilled services and failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form and was given to three Residents (#12, #255 and #256) upon the discontinuation of skilled services. This affected three (Resident's #12, #255 and #256) of three residents reviewed for proper notices of non-coverage. The facility census was 48.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman was notified Resident #38 was transferred to the hospital. This affected one (Resident #38) of three residents reviewed for hospitalizations. The facility census was 48.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide medication administration according to facility policy for Resident #40. This affected one (Resident #40) of four residents observed for medication administration. The facility census was 48.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure Resident #16 received interventions after three days of no bowel movement per the bowel protocol and failed to ensure neurological (neuro) checks were completed for Resident #39 after an unwitnessed fall. This affected one of one resident (Resident #39) reviewed for falls and one (Resident #16) of five residents (Residents #10, #14, #16, #28, #39) reviewed for unnecessary medication. The census was 48.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to develop and implement comprehensive and individualized range of motion treatment and services for Resident #28 to address contractures/limitations in range of motion to the resident's upper left hand. This affected one (Resident #28) of five residents reviewed for range of motion. The facility census was 48.

Inspectors wroteBased on interview and record review the facility failed to have a physician acknowledge pharmacy recommendations for Residents #10, #14 and #39. This affected three (Residents #10, #14 and #39) of four residents reviewed for unnecessary medications. The facility census was 48.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to provide evidence Resident #10 had an attempted or actual gradual dose reduction of antianxiety medication. This affected one (Resident #10) of four residents reviewed for unnecessary medications. The facility census was 48.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to have a physician's order for Resident #40's emergency inhalation medications to be kept at the bedside. This affected one (Resident #40) of four residents reviewed for medication storage. The facility census was 48.