Health inspection·June 2, 2023

F 0689 Detective #109 and the resident's granddaughter. The resident was placed on one on one supervision from staff until he was discharged from the facility on [DATE] at 5:48 P.M. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] at 6:07 P.M. the facility in-house census was 40 residents. A headcount was performed by Registered Nurse (RN) #108 and RN #235 which confirmed all 40 residents were accounted for once Resident #4 returned to the facility. • On [DATE] at 6:10 P.M. RN # 235 obtained vital signs, completed a head to toe assessment, pain assessment, skin assessment, and elopement assessment for Resident #4. No abnormalities were noted. No physical distress was noted. The resident was placed on one on one (1:1) supervision to maintain safety immediately upon return to the facility. A schedule was assembled to provide consistent 1:1 by staff from [DATE] at 6:10 P.M. until discharge [DATE] at 5:48 P.M. Various STNAs provided this continual coverage. • On [DATE] 6:30 P.M. Activities Director #218 verified the front door alarm was functioning correctly and was audible from the employee breakroom which was in direct proximity to the employee work areas. • On [DATE] at 6:59 P.M. RN #235 notified Resident #4's wife and Physician #300 of the elopement. • On [DATE] at 7:00 P.M. the Director of Nursing (DON) initiated education for 15 staff present in the building which included two RNs, two Licensed Practical Nurses (LPNs), eight State Tested Nursing Assistants (STNAs), two dietary aides, and one activity aide). Staff working were educated on the facility elopement policy, elopement drill policy, appropriate response when answering alarms, wandering, and resident safety to include making frequent rounds when not delivering resident care, all staff answering call lights, and staff continuing to have a frequent presence in the hallways to ensure responses to alarms including nurses during medication administration. • On [DATE] at 8:00 P.M. the DON completed an elopement assessment for all 40 residents in the facility. No new residents were identified to be at risk for elopement. • On [DATE] at 8:00 P.M. the DON educated 37 staff (two RNs, eights LPNs, 12 STNAs, one social service member, five dietary staff, one admissions staff, two maintenance staff, one laundry aide, one transport staff, one business office staff and three housekeeping staff) by group text message on the updated elopement policy and procedure. The policy and procedure was updated by RN #301 on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 Level of Harm - Immediate jeopardy to resident health or safety The update included completing a head count whenever staff were unable to decipher the cause of a facility alarm and focus areas of response time and monitoring the exit areas routinely. New staff would be educated by Human Resources on the elopement policy and procedure upon hire, annually, and as needed. • Residents Affected - Few On [DATE] at 8:35 P.M. all 52 facility staff received education on wandering, elopement, responding to alarms and resident safety in person or via phone by the DON. Any staff on leave were not permitted to work after [DATE] until they received education on their next scheduled workday. In addition, Dietary Aide #103 received a verbal counseling by the Administrator on [DATE]. • On [DATE] at 3 P.M. the DON reviewed all resident care plans for elopement risk and appropriate interventions. LPN #200 updated Resident #4's care plan to reflect the resident was placed on 1:1 supervision. • On [DATE] at 10:00 A.M. Maintenance Director #233 assessed all door alarms to ensure the alarms were functioning correctly. No issues were identified. • On [DATE] Maintenance Director #233 contacted the alarm company regarding the facility alarm system. The system was determined to be at maximum volume. A quote to install additional door monitoring systems at each nurse's station from the alarm company was obtained, approved, and awaiting a tentative date of installation. • On [DATE] a statement from Activities Director #218 verified the front door alarm was audible in resident care areas on the [NAME] Hall. Staff interviews reflected the alarm was audible prior to and following incident with Resident #4. STNA #100 and STNA #101 responded to the alarm at 4:30 P.M. as they approached from the [NAME] Wing where the alarm could be heard. • On [DATE] a plan for Human Resources Manager #303 to provide new hires and agency staff with education on wandering, elopement, and resident safety in writing and verbally reiterated by HR during general orientation tour, onsite was implemented. • On [DATE] at 11:00 A.M., the Director of Nursing and Administrator were educated by Regional Quality Assurance (QA) RN #301 on reviewing all referrals and provided education to deny any referrals for residents who were identified as an elopement risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 • Level of Harm - Immediate jeopardy to resident health or safety Beginning [DATE] a plan for the Administrator/designee to complete elopement drills to ensure all staff responded appropriately on random shifts two times per week for four weeks was implemented. • Residents Affected - Few Beginning [DATE] a plan for the Director of Nursing/Designee to review three random residents' nurses notes daily to ensure any documented wandering or elopement behaviors were addressed timely. • Beginning [DATE] a plan for the DON/Designee to conduct interviews/audits of three random staff members from various shifts and departments related to elopement/wandering. This would continue five times a week to monitor staff competency of elopement prevention for four weeks. • Beginning [DATE] a plan for the Maintenance Director/Designee to conduct audits on three door alarms three times a week for four weeks, then randomly thereafter was implemented. • Beginning [DATE] a plan for the Administrator to review the current Facility Assessment to ensure it identified that no residents who were at risk for elopement could reside in the facility. • On [DATE] the Quality Assurance Performance Improvement (QAPI) team reviewed and interpreted all investigation and audit findings as well as completed a root cause analysis. A plan for all ongoing audits and findings to be discussed at the monthly QAPI meeting for a minimum of three months or until a pattern of compliance was maintained. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, muscle wasting and atrophy, need for assistance with personal care, muscle weakness, difficulty walking, and hypertension. Review of Resident #4's care plan, dated [DATE] revealed the resident was at risk for falls and potential injury related to impaired gait and mobility and level of assistance required for transfers. Contributing factors included weakness, gait, strength, and muscle endurance. Interventions included sufficient lighting, common items within reach, provide rest periods, room close to nurse's station and transfer with one assist. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a moderate cognitive impairment, required supervision with one-person physical assistance for walking in the corridor, utilized a walker, and was unsteady but able to stabilize without staff assistance. The MDS did not indicate the resident had wandering behaviors during the assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 period. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #4's elopement evaluation, dated [DATE] revealed the resident was at moderate risk for elopement. The assessment revealed the resident attempted to open exit doors, hovered near exit doors, was oriented to self only, and was ambulatory. Residents Affected - Few Review of Resident #4's Fall Risk Evaluation -V2, dated [DATE], revealed the resident was at risk for falls due to impaired cognition, Alzheimer's/dementia, was visually impaired, wandered, was non-compliant, restless, had an unsteady gait, used an assistance device for mobility, had bladder incontinence, and received anti-anxiety medication. Review of Resident #4's care plan, dated [DATE], revealed the resident was at risk for elopement and wandering related to dementia, expressed intent to leave facility, impaired cognition, unawareness of safety needs, and attempting to follow visitors out the door. Interventions included assess risk factors, attempt to involve in decision-making, encourage participation in activities, family conference to discuss resident attempts to leave, follow facility elopement procedures, monitor, and report changes in behavior (restlessness, pacing, etc.), provide diversional activities of interest as needed, and redirect as needed. Review of the resident's progress notes from [DATE] through [DATE] revealed no documentation regarding the resident's exit seeking behavior(s) or the resident leaving the facility without staff knowledge. Review of the local Police Department, Ohio Uniform Incident Report dated [DATE], revealed on [DATE] at 5:58 P.M. Detective #109 was dispatched to a home on a residential street to investigate a gentleman who seemed confused, and who was trying to get into a (parked) car. The detective arrived on scene at 5:59 P.M. Upon arrival, the detective spoke to Resident #4, and he advised he lived at a nursing facility down the road. The resident seemed confused about most things, but the detective started to help him into his car to see if he did live at the facility. A young lady pulled up and advised that he was her grandfather. She gave him the resident's name and her name and advised he does stay at the facility down the lane. Observation of the facility's camera footage of the incident revealed on [DATE] at 5:18 P.M. Resident #4 walked to the main door and attempted to push it open. It did not open, and he walked away. At 5:20 P.M. State Tested Nursing Assistant (STNA) #100 and STNA #101 were witnessed turning off the alarm to the main door. At 5:28 P.M. Resident #4 approached the door again, leaned against the door until it opened 15 seconds later. He exited the facility with his rollator walker. At 5:35 P.M. Dietary Aide #103 was observed walking over to the main door, turning off the alarm, pulling the door shut, and then returning to work. He did not walk out the front door to investigate what set the alarm off. At 6:07 P.M. Resident #4 was observed returning to the facility without his rollator walker. The DON confirmed the observations of the footage during an interview on [DATE] at 4:00 P.M. Review of the facility investigation of the incident on [DATE] at 5:28 P.M. revealed Resident #4 left the facility through the main door. The resident exited the building with his rollator and walked down the drive to the main road. As part of the facility investigation, the following staff statements were obtained: A handwritten statement dated [DATE], completed by STNA #104, revealed the last time she saw (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #4 (on [DATE]) was after dinner when she and another STNA (not identified) caught him trying to go out the back door by the dumpsters. The statement included the other STNA and I got him back in and made sure the door was latched, then he went up the hall towards [NAME] Hall. A handwritten statement dated [DATE], completed by STNA #107, revealed Resident #4 went missing (on [DATE]) but she did not hear an alarm sound. At 6:10 P.M. a family member and the police returned the resident to the facility without his walker. She reported the last time she saw the resident was when she provided him with his dinner tray. The time was not indicated. An undated handwritten statement, completed by STNA #101, revealed the last time she saw Resident #4 (on [DATE]) was when she and STNA #105 went outside with the dinner people. (the facility did not indicate what dinner people meant). STNA #105 was telling the resident to go inside while he was trying to come outside. The STNA's statement also included, shut the alarms off at least 4:30ish and I was with a kitchen girl. Nobody was around-we looked. A handwritten statement dated [DATE], completed by STNA #105, revealed the last time she saw Resident #4 (on [DATE]) was when he was trying to get out of the door where the dumpsters were when someone was going out (of the building); he was trying to push his way out. She and STNA #104 got him in (the building) and he started walking towards the [NAME] Hall (the hall located near the front entrance). Interview on [DATE] at 11:46 A.M. with STNA #104 revealed she was one of the STNAs assigned to care for Resident #4 on [DATE]. She stated the resident had always wandered since his admission to the facility. She went on to say the resident was easily redirected away from the exit doors. She stated on [DATE] the resident attempted to exit one of the back doors by the dumpster as someone else was walking out. She was able to redirect him back inside and he started walking to the [NAME] Hall. She continued that he was able to exit through those doors (the main door, also known as the west door) although no one in the facility had seen him go or knew he was missing until the police brought him back. She confirmed she did not hear the alarm go off. Interview on [DATE] at 1:22 P.M. with Dietary Aide (DA) #103 revealed he worked on [DATE] and had heard Resident #4 went out the back door and he believed STNA #101 brought him back in. Shortly after that he stated he went to use the bathroom and heard the front door alarm sounding and went to the doors. DA #103 stated he peeked out but didn't go outside because he didn't see anything outside. Further interview revealed he was not sure what to do because he had not been briefed on elopement and did not know the facility procedures. He stated he turned off the alarm and went to the bathroom. When he returned to the kitchen, he stated he thought he said something to Dietary Aide #106 about turning off the alarm. DA #103 stated he later heard Resident #4 got out of the facility and the police had to bring him back. Interview on [DATE] at 3:34 P.M. with STNA #107 revealed she was assigned to Resident #4 on [DATE]. She continued that she was not aware Resident #4 left the building until the police returned him after 6:00 P.M. that night. She stated the resident frequently was exit seeking and she did not feel like the facility was equipped to care for residents like him (who were exit seeking). She stated she was not aware of his exit seeking behaviors that day. Interview on [DATE] at 3:48 P.M. with STNA #105 revealed the only interaction she had with Resident #4 was earlier in the day on [DATE] at around 1:00 P.M. to 2:00 P.M. She stated the resident was trying to exit the facility though the door by the dumpsters. The resident was directed back inside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the building. She stated later in the day around 6:00 P.M. she answered a call from the police department asking if one of the facility's residents were missing. Further interview revealed, when leaving that night, she found Resident #4's rollator walker about halfway down the drive, beside the mental health facility that was located on the same road as the facility. She also stated she did not hear any alarms going off that day. Interview on [DATE] at 8:53 A.M. with Registered Nurse (RN) #108 revealed she was working on [DATE], was familiar with Resident #4 and knew he was an elopement risk. The RN denied hearing the door alarm or knowledge of him missing until the police called and said they had found a resident. RN #108 denied staff reporting to her Resident #4 was exit seeking on [DATE]. Telephone interview on [DATE] at 10:51 A.M. with Police Detective #109 revealed on [DATE] at 5:58 P.M. he received a call from a woman stating someone was trying to get into her car at the end of the street. He stated he arrived on scene at 5:59 P.M. and observed Resident #4 on the corner of the lane and the main street. The resident was able to point and indicated he lived down the lane. The resident's granddaughter also happened to arrive on scene at this time. The detective confirmed the resident did not have a walker and was confused. The resident's granddaughter put him in her car and drove him back to the facility while the detective followed. The staff at the facility were not aware the resident had left the building. Interview on [DATE] at 4:49 P.M. with Family Member #110 revealed she was driving down the road on [DATE] around 5:30 P.M. when she saw a police car and someone who looked like her family member. She pulled over and the police officer told her the family member was attempting to get into a parked car. Her family member (grandfather) appeared confused and did not have his walker with him. Family Member #110 indicated she took the resident back to the facility and stated she was very upset the facility did not know he was missing. Telephone interview on [DATE] at 12:38 P.M. with Certified Nurse Practitioner (CNP) #111 revealed she oversaw Resident #4's care while he was at the facility. The CNP revealed Resident #4 would not be safe to be outside alone due to poor cognition, unsteady gait, and noncompliance with his walker. Interview on [DATE] at 12:14 P.M. the Director of Nursing (DON) revealed she received a call on [DATE] at 6:20 P.M. from RN #235 stating Resident #4 had eloped from the facility and was brought back to the facility by the resident's granddaughter around 6:10 P.M. A complete assessment was done at the time of his return, and the resident was placed on one-on-one supervision. She stated at the time of the incident, the resident was fully dressed, and it was 73 degrees Fahrenheit outside. The DON stated it was normal behavior for Resident #4 to wander and he was an identified elopement risk. The DON stated an investigation was completed, and by looking at camera footage which determined the resident left the faciity on [DATE] at 5:28 P.M. through the main doors (front entrance). At 5:36 P.M. Dietary Aide #103 responded to the alarm, shut the door, and disabled the alarm without investigating the source of the alarm. She stated Dietary Aide #103 indicated in his statement he notified the [NAME] STNAs (not identified) of the alarm, but camera footage determined this to be untrue. Continued investigation revealed Resident #4 made it to the end of the drive leading to the main road and was found by police and returned around 6:10 P.M. that day. The DON verified the resident's risk for elopement plan of care was not implemented to prevent resident elopement and no additional supervision or interventions were attempted to prevent the resident from eloping. The resident was not safe to be outside of the facility unsupervised. The DON also stated DA #103 should have further investigated the door alarm and reported the door alarm to the appropriate staff. As a result, a verbal warning was issued to DA #103 for failure to report or investigate a door alarm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of DA #103's employee file revealed a disciplinary action Reviewed Notice of Corrective Action, dated [DATE]. Dietary Aide #103 received a verbal warning for shutting off door alarm without looking outside or alerting anyone. Prior to the incident, the most recent elopement education provided to DA #103 was on [DATE]. Review of the undated facility Elopement policy revealed residents who had been determined by the team to be as risk for elopement would receive interventions as the team deems necessary. This may include surveillance checks, a wander guard device (a special bracelet worn by at risk residents to alert staff when the resident is near or attempting to exit an exterior door), distraction method, or alternate placement. The policy did not address responding to door alarms. 2. Review of the closed medical record for Resident #42 revealed an admission date of [DATE] with diagnoses including dementia, metabolic encephalopathy, muscle wasting and atrophy, need for assistance with personal care, difficulty with walking, and disorientation. The resident utilized a wheelchair for movement on and off the unit. The resident was discharged to another facility on [DATE]. Review of Resident #42's admission MDS 3.0 assessment, dated [DATE], revealed the resident had moderate cognitive impairment and required extensive assistance of two staff for transfers and locomotion off the unit. Review of Resident #42's Elopement Assessment, dated [DATE], revealed the resident was a moderate risk for elopement due to demonstrating exit seeking behaviors such as packing belongings, stating they want or need to leave, searching for exit doors, putting on coat, only being orientated to self, and utilized a wheelchair for mobility. Review of a facility investigation dated [DATE] revealed STNA #253 was passing dinner trays and noticed Resident #42 was missing. The missing resident code (verbal notification to all staff) was called at 5:11 P.M. and the resident was found outside near the dumpster four to five minutes later by RN #108. No injuries were noted, all staff were trained on the Elopement and Missing Person Policy, he was assessed, and placed on a one on one until his discharge. The investigation revealed a locked door had been kept open and the resident had been able to exit through this door. The facility was unable to determine if the door was unlocked or propped open allowing the resident to exit the facility unsupervised. The facility investigation included staff statements. A handwritten statement by STNA #253 revealed (on [DATE]) she started passing dinner trays at 5:00 P.M. In the middle of passing dinner trays, she saw Resident #42 at the main entrance of the building. When the STNA got to the resident's room he was not there. An elopement was called at 5:11 P.M. after the STNA checked the rooms and could not find the resident. The STNA stated she started to look outside and found the resident by the dumpsters at 5:15 P.M. Review of a handwritten statement by RN #108 revealed she was alerted Resident #42 was missing (on [DATE]) at dinner time. A search was started, the resident was found outside by the dumpsters and was only missing for approximately four to five minutes. No injuries were noted. Interview on [DATE] at 12:14 P.M. with the DON revealed on [DATE] Resident #42 was able to exit the facility through a door that had not been locked and was open. The resident was gone for four to five minutes and had no injuries when he was found. Following the incident, signs were placed on all the doors to keep them locked and always shut. The DON stated she verbally trained all staff on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 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 366087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Center, The 100 Vista Drive Lisbon, OH 44432 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few keeping the doors shut and locked, on the elopement and missing persons policy and Resident #42 was placed on one-on-one supervision until he was discharged from the facility on [DATE]. Review of the undated facility Elopement policy revealed residents who had been determined by the team to be as risk for elopement would receive interventions as the team deems necessary. This may include surveillance checks, a wander guard device (a special bracelet worn by at risk residents to alert staff when the resident is near or attempting to exit an exterior door), distraction method, or alternate placement. The policy did not address responding to door alarms. This deficiency represents non-compliance investigated under Complaint Number OH00143070. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366087 If continuation sheet Page 9 of 9