Health inspection·August 20, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed on 06/19/25 revealed Resident #41 had a Stage two (II) pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the sacrum that measured 1.5 centimeters (cm) by 1.2 cm by 0.2 cm with an onset date documented as 06/19/25 related to a leave of absence (LOA) or ER visit. The wound tissue was documented as 100 percent (%) pink with moderate serosanguinous exudate (drainage) and no signs of infection. The peri wound (tissue surrounding the wound) was intact, fragile, and moist. The medical record revealed no comprehensive wound assessment or tracking between 06/19/25 and 07/03/25, including the wound size (length, width, depth), wound stage, amount, color, consistency, and odor of wound exudate, wound bed tissue, wound edges and surrounding skin, signs of infection or inflammation, presence of pain, and status (healing, stalled, stable, declined). However, there was a weekly skin assessment completed on 06/25/25 which revealed Resident #41 had an open lesion. The note further revealed Open areas to coccyx. The assessment did not indicate there had been a previously identified pressure area and there was no comprehensive wound assessment documented. Review of the physician orders revealed orders dated 06/26/25 for Resident #41 to have house liquid protein supplements, 30 milliliters (ml), twice daily by mouth for 60 days (the pressure ulcer was first identified on 06/12/25). Review of the Skin Grid Pressure 3.0 - V 2 assessment completed on 07/03/25 revealed Resident #41 had an unstageable pressure area (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the sacrum which measured 2.0 cm by 1.5 cm by an undeterminable depth. The wound was listed as in-house acquired and contained 80% slough. The wound was noted to have a moderate amount of serosanguinous exudate, and the peri-wound area was moist and reddened. The wound status was listed as having declined since the previous assessment. The Skin Grid Pressure 3.0 - V 2 assessment completed on 07/10/25 revealed a full-thickness unstageable pressure ulcer to the sacrum that measured 2.0 cm by 2.0 cm by an undeterminable depth. The wound bed contained 20% granulation tissue and 80% slough with undermining to an undeterminable extent due to the slough. The peri-wound was reddened and Resident #41 experienced tenderness with wound care. The assessment indicated no assessment of the wound healing status. Review of the Encore Wound Care visit note dated 07/10/25 revealed this was the date of the initial wound provider consultation for an unstageable pressure ulcer that was in-house acquired. Further review of the note revealed Resident #41 had a sharp excisional debridement of one square centimeter where loose slough was excised to better visualize the wound base and the debrided tissue went down to the subcutaneous tissue. At the time of the visit, new orders for wound care were initiated and recommendations included offloading pressure, proper nutrition and protein supplementation with a nutrition consult per facility policy, pressure reducing devices to the bed and wheelchair, repositioning per facility protocol, proper hygiene, avoiding contamination, and changing dressings PRN to keep clean and dry. The treatment order was to clean the wound with NSS, pack with silver alginate rope (if the facility was able to order the reinforced silver alginate rope), and cover with a silicone super absorbent dressing daily and PRN. Review of the physician orders dated 07/10/25 revealed Resident #41 was to have the coccyx wound cleansed with NSS, packed with calcium alginate rope, and covered with a foam dressing daily and PRN. There were no progress notes dated 07/10/25 indicating the facility was unable to order reinforced silver alginate rope or silicone super-absorbent dressings or that the facility had discussion with and/or received additional order clarification from Wound Advance Practice Registered Nurse (APRN) #325, the practitioner managing the wound care from Encore Wound Care. Review of the TAR from July 2025 revealed this treatment was documented daily from 07/10/25 through 07/31/25, except 07/21/25, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 2 of 9 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 08/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contained no electronic signature. Review of the assessments, progress notes, and wound provider (Encore) visit notes revealed no comprehensive wound assessment or tracking was completed between 07/10/25 and 07/24/25, although there was a weekly completed on 07/16/25 which noted Resident #41 had a bruise and a previously identified pressure area with a treatment in place. Review of the Encore Wound Care visit note dated 07/24/25 revealed Resident #41 reported the wound was on fire at the time of the visit. Further review of the note revealed the wound had declined and was reclassified as a Stage four (IV) pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling). The note also revealed Resident #41 had poor nutritional intake, had an overall poor health condition, was incontinent, and had poor compliance with offloading. Review of the visit note revealed the wound had grown to 3.0 cm by 2.8 cm by 1.6 cm with undermining from 12 o'clock to 12 o'clock for a maximum of 1.9 cm depth at three o'clock and 1.2 cm at six o'clock, 60% exposed fascia, and heavy serosanguinous drainage. The wound care orders were changed during this visit due to the heavy drainage with new recommended treatment consisting of cleansing the wound with NSS, packing with calcium alginate rope, and covering with a silicone super absorbent dressing every shift and PRN. Review of the Skin Grid Pressure 3.0 - V 2 assessment completed on 07/24/25 mirrored the assessment from the Encore wound visit note for this date. Review of the orders revealed no new treatment orders after Encore APRN #325 changed the order recommendation during the visit on 07/24/25. Review of the Encore Wound Care visit note dated 07/31/25 revealed Resident #41 was positive for Clostridioides difficile (C. diff., a bacterium that causes diarrhea and inflammation of the bowel), was on oral antibiotics, and appeared not well-nourished. The wound was classified as improving during the visit and no new wound care orders or recommendations were made (the treatment order remained for Resident #41 to have the wound cleansed with NSS, packed with calcium alginate rope, and covered with a silicone super absorbent dressing every shift and PRN). Review of the physician orders revealed a new treatment order dated 08/01/25 which was for Resident #41 to have the sacral wound cleaned with NSS or wound cleanser, pat dry, lightly pack with calcium alginate rope, and cover with a silicone super absorbent dressing every day shift for wound management (not every shift and PRN as specified by Wound APRN #325 on 07/24/25 and 07/31/25). Review of the TAR from August 2025 revealed wound care was documented once daily, except on 08/04/25, where there was no electronic sign-off the treatment had been completed. Review of the Encore Wound Care visit note dated 08/07/25 revealed Resident #41's wound status was measuring 4.0 cm by 3.0 cm by 2.0 cm with deepest undermining at 11 o'clock at 3.0 cm and the wound bed contained 60% granulation, 10% bone, and 30% fascia. Further review of the note revealed Resident #41 was advised that further wound decline was possible and was informed further work-up could be done, which included possible hospitalization and intravenous antibiotics, but Resident #41 declined further evaluation or treatment at that time, and the facility was to continue with the same plan of care for another one to two weeks and then the wound care orders would be reviewed for continued appropriateness. The continued wound care order per Wound APRN #325 was to clean the wound with NSS, pack with calcium alginate rope, and apply a silicone super absorbent dressing every shift and PRN (The August 2025 TAR revealed treatments continued to be performed every day shift instead of every shift). Review of the physician orders revealed an order dated 08/07/25 for Resident #41 to have an alternating pressure air mattress to the bed and staff were to check the mattress for proper functioning every shift. Review of the care plan (initiated on 05/28/25) revealed an update was made on 08/14/25 to reflect Resident #41 had actual impaired skin integrity related to a Stage II pressure ulcer to the sacrum (note: the impaired skin integrity/pressure ulcer initially developed on 06/12/25 and had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 3 of 9 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 08/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been reclassified as a Stage IV on 07/24/25). Interventions included referring to a wound physician PRN, administering medications and wound care per physician orders, completing skin documentation and skin assessments per facility policy, explaining procedures prior to care, monitoring signs of infection, and notifying the physician of wound deterioration. Interview on 08/13/25 at 2:35 P.M. with Certified Nurse Aide (CNA) #354 revealed Resident #41 had a large wound that was believed to be noted after a recent hospital visit. CNA #354 denied any concerns related to wound care at the time of the interview. Interview on 08/13/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #350 revealed Resident #41 had a wound on her coccyx area for a couple weeks that had gotten larger. During the interview, LPN #350 confirmed the wound treatment was scheduled to be completed once a day (Wound APRN #325 ordered for wound care to be completed every shift) and it would get changed on a PRN basis if it was soiled. At the time of the interview, when asked of the dressing change had been completed earlier in the shift, LPN #350 did not respond definitively. Observation on 08/13/25 from 3:18 P.M. to 3:35 P.M. of wound care for Resident #41 performed by LPN #350 revealed a gown, mask, face shield, and two pairs of gloves were donned prior to entering the room of Resident #41. As the personal protective equipment (PPE) was being applied, LPN #350 stated double-gloving would be used to minimize movement around the room during wound care between steps of the procedure so that one pair could be removed once the old dressing was off and the other pair of gloves could be used to continue wound care without stepping away to perform hand washing between glove changes. Before wound care commenced, two normal saline bullets, dry gauze, a package containing calcium alginate rope, and a package containing a silicone absorbent border dressing were laid on the bedside stand without the bedside stand being cleaned or a barrier set-up for the dressing supplies. The packaging for the calcium alginate rope and silicone border dressing were opened slightly (the seal was opened one edge of each package, but the other three edges remained intact, and the packages remained closed over top of the dressing supplies). LPN #350 was observed removing the old dressing, which was undated and soiled in urine and stool, wrapped the old dressing in the top layer of gloves, removed the top layer of gloves, and discarded in the trash can at the bedside. While wearing the bottom layer of gloves, LPN #350 squirted two 15 milliliter (ml) saline bullets onto the wound bed, wiped around the wound bed with dry gauze, used the gloved hands to manipulate the package containing the calcium alginate rope, used the same gloved hands to press the calcium alginate rope into the wound bed and undermined edges, then grabbed the package containing the silicone border dressing, removing the dressing from the package, and secured the border dressing over the wound. With the same gloved hands, LPN #350 repositioned Resident #41 in bed and adjusted the bed linen. At this time, LPN #350 was observed removing the old gloves and applying new gloves to raise the head of the bed for Resident #41 and assisting with a drink of water. No hand hygiene was performed between the glove changes. An interview with LPN #350 on 08/13/25 at 3:40 P.M. confirmed double gloving was the process always used to provide wound care in the facility so there was less need to go back and forth to perform hand hygiene. During this interview, LPN #350 also confirmed no hand hygiene was performed between glove changes after the wound care observation. Interview on 08/14/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed Encore Wound Care was the outside company the facility used to manage wounds. The DON further confirmed residents with any type of wound, not just chronic wounds, were to be referred to Encore Wound Care for an initial consultation and that Wound APRN #325 from Encore is the Provider who managed wound care orders for Resident #41. During the interview, the DON reported Resident #41 acquired the pressure ulcer during an ER visit (on 06/18/25) and presented the Skin Grid Pressure 3.0 - V 2 assessment from 06/19/25 indicating the onset date of 06/19/25 acquired after a leave of absence (LOA) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 4 of 9 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 08/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or ER visit. At this time, the DON verbalized uncertainty regarding treatments to the coccyx being initiated one week prior to the facility documented wound onset of 06/19/25 and confirmed if there were wound assessments completed on 06/26/25 and 07/17/25, she would produce them. No documentation of weekly comprehensive wound assessments were presented during the survey. Also, during this interview, the DON confirmed hand hygiene was to be performed between glove changes and double gloving was not common practice for the facility, but she would look further into it. The DON further confirmed nurses were supposed to clean the bedside stand and set up a clean barrier prior to setting up their dressing supplies. Interview on 08/14/25 at 9:42 A.M. with Regional Quality Assurance (QA) Nurse #320 confirmed nurses should not double glove to provide wound care. Interview on 08/14/25 at 3:10 P.M. with Resident #41 confirmed no wound was present upon readmission to the facility (05/28/25) and that the wound was acquired while in the facility, not in the hospital, and that it hurt. Resident #41 further confirmed the wound had already been present and nurses were doing dressings on her backside before any of the visits to the ER. Interview on 08/14/25 at 2:48 P.M. with Regional QA Nurse #320 confirmed the original care plan focus for Resident #41 being at risk for altered skin integrity or pressure ulcer development was not all inclusive of possible preventative measures and the care plan would be re-evaluated. During the interview, Regional QA Nurse #320 confirmed she updated the care plan on 08/14/25 to reflect the actual altered skin integrity and that the alteration noted Resident #41 had a Stage II pressure ulcer. At this time, Regional QA Nurse #320 was notified the pressure ulcer had regressed to a Stage IV as of 07/24/25 and Regional QA Nurse #320 confirmed the care plan would need updated. Telephone interview with LPN #357 on 08/18/25 at 3:39 P.M. confirmed the aide 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 5 of 9 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 08/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 6 of 9 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 08/20/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. This affected two residents (Residents #35 and #41) but had the potential to affect eight residents who were identified by the facility as having wounds (Residents #21, #28, #33, #41, #42, #44, #45, and #50) and six residents who were in droplet isolation (Residents #19, #21, #26, #27, #35, and #44). The facility census was 51. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 03/09/25 and a re-entry date of 05/28/25. Diagnoses included unspecified dislocation of the right hip, adult failure to thrive, presence of bilateral artificial knee joints, Parkinson's Disease, tachycardia, primary hypertension, osteoarthritis, and need for assistance with personal care. Review of the care plan dated 05/28/25 revealed Resident #41 was at risk for infection related to a chronic wound. Interventions included maintaining enhanced barrier precautions (EBP) as indicated. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/10/25 revealed Resident #41 had intact cognition and was dependent for toileting hygiene, bathing, transfers in and out of bed and required substantial assistance to roll left and right in bed. Further review of the MDS revealed Resident #41 had occasional bladder incontinence and was at risk for pressure injury but had no pressure injuries, ulcers, lesions, rashes, surgical wounds, burns, skin tears, or moisture associated skin damage (MASD) at the time of the assessment. Review of the physician orders revealed an order dated 07/29/25 for Resident #41 to be in contact isolation with no further description or instructions. Further review of the order revealed contact isolation was discontinued on 08/11/25. Review of the physician orders also revealed a treatment order dated 08/01/25 which was for Resident #41 to have the sacral wound cleaned with NSS or wound cleanser, pat dry, lightly pack with calcium alginate rope, and cover with a silicone super absorbent dressing every day shift for wound management. Observation on 08/13/25 at 2:35 P.M. revealed one cart containing PPE, one covered bin for trash, and one covered bin for linen in the hall outside the door to the room of Resident #41. Further observation revealed there were two signs hanging on Resident #41's door, one that specified Resident #41 was in EBP and one identifying Resident #41 as requiring contact isolation. Interview on 08/13/25 at 2:35 P.M. with Certified Nurse Aide (CNA) #354 revealed the belief Resident #41 was in EBP for a large wound and no knowledge as to why the contact isolation sign was on the door. Interview on 08/13/25 with Licensed Practical Nurse (LPN) #350 revealed a statement that contact isolation and EBP were the same thing and the contact isolation sign was probably there to remind staff which PPE to wear when providing care to Resident #41 because she had a large wound. Observation on 08/13/25 from 3:18 P.M. to 3:35 P.M. of wound care for Resident #41 performed by Licensed Practical Nurse (LPN) #350 revealed a gown, mask, face shield, and two pairs of gloves were donned prior to entering the room of Resident #41. As the PPE was being applied, LPN #350 stated double-gloving would be used to minimize movement around the room during wound care between steps of the procedure so that one pair could be removed once the old dressing was off and the other pair of gloves could be used to continue wound care without stepping away to perform hand washing between glove changes. Before wound care commenced, two normal saline bullets, dry gauze, a package containing calcium alginate rope, and a package containing a silicone Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 7 of 9 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 08/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few absorbent border dressing were laid on the bedside stand without the bedside stand being cleaned or a barrier set-up for the dressing supplies. The packaging for the calcium alginate rope and silicone border dressing were opened slightly (the seal was opened one edge of each package, but the other three edges remained intact, and the packages remained closed over top of the dressing supplies). LPN #350 was observed removing the old dressing, which was undated and soiled in urine and stool, wrapped the old dressing in the top layer of gloves, removed the top layer of gloves, and discarded in the trash can at the bedside. While wearing the bottom layer of gloves, LPN #350 squirted two 15 milliliter (ml) saline bullets onto the wound bed, wiped around the wound bed with dry gauze, used the gloved hands to manipulate the package containing the calcium alginate rope, used the same gloved hands to press the calcium alginate rope into the wound bed and undermined edges, then grabbed the package containing the silicone border dressing, removing the dressing from the package, and secured the border dressing over the wound. With the same gloved hands, LPN #350 repositioned Resident #41 in bed and adjusted the bed linen. At this time, LPN #350 was observed removing the old gloves and applying new gloves to raise the head of the bed for Resident #41 and assisting with a drink of water. No hand hygiene was performed between the glove changes. An interview with LPN #350 on 08/13/25 at 3:40 P.M. confirmed double gloving was the process always used to provide wound care in the facility so there was less need to go back and forth to perform hand hygiene. During this interview, LPN #350 also confirmed no hand hygiene was performed between glove changes after the wound care observation. Interview on 08/14/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed hand hygiene was to be performed between glove changes and double gloving was not common practice for the facility, but she would look further into it. The DON further confirmed nurses were supposed to clean the bedside stand and set up a clean barrier prior to setting up their dressing supplies. During this interview, the DON confirmed Resident #41 had previously tested positive for Clostridioides difficile (C. diff., a bacterium that causes diarrhea and inflammation of the bowel), but had completed the antibiotics, was having formed stools, and the sign should no longer be posted outside the door. Interview on 08/14/25 at 9:42 A.M. with Regional Quality Assurance (QA) Nurse #320 confirmed nurses should not double glove to provide wound care. 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. 2. Review of the medical record for Resident #35 revealed an initial admission date of 07/08/24 and a re-entry date of 07/30/24 with diagnoses including unspecified mood disorder, unspecified psychosis, ulcerative colitis, pulmonary fibrosis, Alzheimer's disease, malignant neoplasm of the colon, and colostomy status. Review of the diagnoses revealed Resident #35 also had COVID-19 as of 08/10/25. Review of the annual MDS 3.0 assessment completed on 07/16/25 revealed Resident #35 had moderately impaired cognition and had been independent with eating, oral hygiene, and toileting hygiene, and required supervision of touching assistance with bathing. Review of the MDS further revealed Resident #35 had an ostomy for bowel elimination. Review of the orders revealed and order dated 08/11/25 for Resident #35 to be in strict isolation with droplet precautions through 08/20/25 secondary to COVID-19 infection. Review of the care plan dated 08/15/25 revealed Resident #35 had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365760 If continuation sheet Page 8 of 9 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 08/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete actual infection related to COVID-19 and was in isolation until 08/20/25. Interventions included providing isolation per protocol through the infectious period. Review of the progress notes revealed a noted dated 08/11/25 at 3:10 P.M. indicating Resident #35 tested positive for COVID-19 and droplet precautions were to be maintained. Observation on 08/18/25 at 8:25 A.M. revealed Medication Aide #380 entered the room of Resident #35 with an N-95 mask over a surgical mask, no gown, no gloves, and no face shield or goggles. Medication Aide #380 was observed assisting Resident #35 with drinking sips of orange juice and with eating breakfast. After approximately three minutes into observation, Medication Aide #35 closed the door to the room to assist Resident #35 with additional needs. Interview on 08/18/25 at 8:35 A.M. with Registered Nurse (RN) #371 confirmed Resident #35 was in droplet isolation until 08/20/25 for testing positive for COVID-19. During the interview, RN #371 stated staff were to don gloves, a face shield, and an N-95 mask prior to entering the room of Resident #35 to provide care and any direct personal care would also require a gown. At the time of the interview, RN #371 verbalized that a gown was typically not needed for residents in droplet isolation unless close direct contact was required. 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. Event ID: Facility ID: 365760 If continuation sheet Page 9 of 9