F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based 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.
Findings include:
Observation made on 09/11/23 at 12:42 P.M. with Laundry Aide (LA) #802 of the ice machine located
downstairs by the elevator revealed on the ice guard inside of the ice machine there was a moderate and
thick build-up of pink biofilm containing specks of a black, mold-like substance . Laundry Aide (LA) #802
confirmed the finding during the observation.
Interview on 09/11/23 at 1:00 P.M. with the Maintenance Director (MD) #804 revealed the ice machine was
cleaned every three months and was scheduled to be cleaned at the end of September. MD #804
confirmed there was a visible black mold-like substance and a thick, pink biofilm present inside the ice
machine and this ice machine provided ice to the nursing staff to use for resident consumption.
This deficiency represents non-compliance identified during the investigation of Complaint Number
OH00145765.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365760
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365760
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/13/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Center of Boardman
830 Boardman Canfield Rd
Boardman, OH 44512
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Some
Findings include:
Observations made throughout the survey on 09/11/23 through 09/13/23 of the general facility environment
including resident rooms and common areas on all units revealed multiple fruit flies present in resident
rooms on the C-unit for Resident #5, #13, #15, #25, #29, #31, #44, #46 and #49. The secured unit common
area also had evidence of multiple, live fruit flies buzzing around in the common area.
Interview conducted on 09/11/23 at 1:00 P.M. wth the Maintenance Director (MD) #804 and Licensed
Practical Nurse (LPN) #805 revealed fruit flies have been an issue in the facility, the exterminator comes out
but the problem has not gotten better. MD #804 verified the fruit flies in the C-unit resident rooms and
common area on the secured unit.
This deficiency represents non-compliance identified during the investigation of Master Complaint Number
OH00146214 and Complaint Number OH00145765.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365760
If continuation sheet
Page 2 of 2
