Health inspection·May 1, 2025

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 Page 1 of 4 366087 366087 05/01/2025 Vista Center, The 100 Vista Drive Lisbon, OH 44432

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 366087 Page 2 of 4 366087 05/01/2025 Vista Center, The 100 Vista Drive Lisbon, OH 44432

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 366087 Page 3 of 4 366087 05/01/2025 Vista Center, The 100 Vista Drive Lisbon, OH 44432

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. 366087 Page 4 of 4