F 0562
Provide immediate access to any resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interviews with family, staff, residents, and the Ombudsman, the facility failed to
ensure residents and family members were able to contact facility staff members via the telephone. This
had the potential to affect all residents in the facility. The facility census was 45.
Residents Affected - Many
Findings include:
Review of the two anonymous complaint intake reports reported to the state agency revealed facility staff
did not answer the facility telephones.
Attempted phone calls made by the State agency on 04/29/25 at 5:36 P.M., 04/29/25 at 5:40 P.M., 04/29/25
at 5:44 P.M., and 04/30/25 at 7:07 A.M. revealed the facility staff members did not answer the telephone
and there was not a way to leave a message.
Interview on 04/30/25 at 1:18 P.M., Registered Nurse #60 reported at times she was not able to answer the
phone if they were short staffed. She continued that she did try to return the calls if she was able.
Interview on 04/30/25 at 2:00 P.M., Ombudsman #47 reported she had received complaints from family
members regarding facility staff not answering the telephones. He continued that he had reported the
concern to the facility in the past.
Phone interview on 04/30/25 at 2:20 P.M., Family Member #48 reported she had attempted to contact the
facility on numerous occasions, attempting to check on her family member. She reported several times she
was not been able to get ahold of anyone at the facility. She reported one weekend, she had tried for two
days to get an update on her family member and was unable to get anyone to answer the phone. She
reported she had to call the police department to do a wellness check on her family member. She also
reported that she had outside doctors call her asking questions about her family members because they
reported they were unable to get in contact with anyone at the facility.
Interview on 04/30/25 at 3:00 P.M. Resident #23 reported he had called the facility numerous times, and no
one would answer the calls. A couple of weeks ago he waited 90 minutes for someone to answer his call
light. He reported that they did not respond so he attempted to call the facility to get someone to help him.
He went on to say no one would answer his phone call so he had to call the police to see if he could get
someone to help him. He reported he felt fearful when no one answered his calls.
Interview on 05/01/25 at 12:20 P.M. with the Administrator reported she was aware of concerns
(continued on next page)
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 4
Event ID:
366087
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
05/01/2025
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 0562
Level of Harm - Minimal harm
or potential for actual harm
related to contacting the facility via telephone, but thought they had been resolved. She went on to say she
was unaware of issues with the phone system on 04/29/25 and 04/30/25.
This deficiency represents non-compliance investigated under Master Complaint Number OH00164268 and
Complaint Number OH00163222.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366087
If continuation sheet
Page 2 of 4
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
05/01/2025
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and medical record review, the facility failed to ensure Resident #43
received the correct oxygen dosing and failed to ensure Resident #5's nebulizer equipment and mouthpiece
were appropriately stored. This affected two out of three residents reviewed for respiratory care. The facility
census was 45.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #43 revealed an admission date of 11/22/23. Diagnoses
included metabolic encephalopathy, dementia, dysphagia, and diabetes mellitus type two.
Review of Resident #43's physician orders revealed an order dated 03/15/25 for continuous oxygen at two
liters per minute via nasal cannula.
Review of Resident #43's care plan dated 04/02/25 revealed the resident had an alteration in respiratory
function and required oxygen use with an intervention to administer oxygen as ordered.
Review of Resident #43's Treatment Administration Record revealed facility nurses signed off that the
resident oxygen was set to two liters on both 04/29/25 and 04/30/25.
Observations made on 04/29/25 at 9:25 A.M., 04/29/25 at 11:25 A.M., and 04/30/35 at 2:30 P.M. revealed
Resident #43 oxygen was at set at 3.5 liters per minute.
Interview on 04/30/25 at 2:38 P.M., Registered Nurse #50 confirmed Resident #43's oxygen was at 3.5
liters per minute and that it should have been placed at two liters per minute. She adjusted the oxygen.
2. Review of the medical record for Resident #5 revealed an admission date of 07/08/22. Diagnoses
included chronic obstructive pulmonary disease (COPD), dysphagia, and dependence on supplemental
oxygen.
Review of Resident #5's physician orders revealed orders dated 07/08/22 for Ipratropium-albuterol solution
0.5-2.5 (3) milligrams (mg) per 3 milliliter (ml) with instructions to inhale 3 ml orally every four house as
needed for COPD or shortness of breath.
Review of Resident #5's care plan dated 04/11/25 revealed the resident had an alteration in respiratory
function and required oxygen use with interventions to administer medications, oxygen and aerosol
treatments as ordered. The care plan further revealed the resident had an alteration in respiratory function
related to COPD with interventions to provide respiratory treatments per physician orders.
Observation on 04/29/25 at 10:55 A.M. revealed Resident #5's nebulizer machine (a medical device used to
deliver medication in the form of a mist or aerosol directly into the lungs) was sitting directly on the floor.
The top of the machine was covered in an unknown dried substance. The mouthpiece was lying on top of
the machine touching the top of the machine and wall.
Interview on 04/29/25 at 10:55 A.M., Resident #5 reported the nurses stored the nebulizer on the floor
because there was not enough table space in his room. He stated he would prefer it not to be on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366087
If continuation sheet
Page 3 of 4
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
05/01/2025
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 0695
the floor.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/29/25 at 11:10 A.M., Licensed Practical Nurse (LPN) #29 confirmed the findings and
moved the machine and mouthpiece from the floor to his bedside table and cleaned the top of the machine.
Residents Affected - Few
This deficiency represents non-compliance investigated under Master Complaint Number OH00164268 and
Complaint Number OH00163713.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366087
If continuation sheet
Page 4 of 4