Health inspection·February 19, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of invoices, and interview, the facility failed to provide a comfortable, clean environment for residents when there was a pervasive smell of sewage in the facility shower room which carried into the hallway. This affected five residents (#2, #14, #28, #18, and #24) identified as using the shower room. The facility census was 46.Findings include:On 02/17/26 at 9:42 A.M., an observation of the facility shower room revealed an overwhelming odor of sewage, which caused the surveyor's eyes to water. The hallway nearest to the shower room also smelled of sewage, though not as strong. This was confirmed at the time of the observation by the Maintenance Director (MD).On 02/17/26 at 9:45 A.M., an interview with Certified Nurse Aide (CNA) #164 revealed she knew there were at least three residents who used the shower. She revealed at times, even with the door closed, the odor of Sulphur would come into the hallway. She did not think anyone knew what was wrong with it.On 02/17/26 at 9:48 A.M., an interview with Resident #18 revealed he had been at the facility for three years, and the smell had been there since he got there. He reported one time the facility dumped bleach into the drain and there was some improvement, however, it had just gotten worse lately. He stated, It is f**cking nasty, and I hate to have to get a shower in there, but what option do I have?On 02/17/26 at 9:42 A.M., an interview with the MD revealed the smell in the shower room was about normal. He reported the smell was always there. He indicated plumbers had been to the facility to look at the situation; however, they told him there was nothing wrong. He reported that no residents use the shower during the day, it was only used on night shift, and housekeeping was able to come to the shower room and clean it during the day, which would help mitigate the odor.On 02/17/26 at 3:00 P.M., an interview with the Maintenance Director revealed the plumbing service had returned and checked the shower room on that day. He reported the plumber told him there was nothing wrong with the plumbing.On 02/17/26 at 12:48 P.M., an interview with Plumber #400 revealed his company had been to the facility on at least two occasions, including the day of survey to inspect the sewer smell coming from the shower room. He indicated on the first visit the plumber advised the MD there was a leak in the toilet in the shower room. They advised him the toilet needed pulled, a new seal and new bolts needed to be placed on the toilet. If this was not done, every time a toilet was flushed in the facility, the sewage odor would escape through the leaking toilet in the shower room.Plumber #400 reported his crew returned to the facility on [DATE] and found the issue had not been corrected. The technician advised the MD told them he knew what needed completed on the toilet, and he told them he probably should have completed the work the last time the plumbers advised him of this.On 02/19/26 at 12:17 P.M., an interview with an anonymous family member revealed any time their family member went to the shower room it was dirty. They reported it smelled like plain old sewage, and looked like it was never cleaned. There was always hair and debris in the drains. This had been happening for several months.Review of invoices from the contracted Page 1 of 6 366087 366087 02/19/2026 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0584 Level of Harm - Minimal harm or potential for actual harm plumbing service revealed services were rendered on 11/25/25 and 02/17/26. The invoice dated 11/25/25 indicated services were for checking for smell in drain. No trapped drain for shower room and its open. The invoice dated 02/17/26 indicated ran floor drain into main line in tub room.This deficiency represents non-compliance investigated under Complaint Number 2733050 and 2638657. Residents Affected - Some 366087 Page 2 of 6 366087 02/19/2026 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, sampled test tray, and interview the facility failed to provide palatable meals at preferred temperatures to residents. This had the potential to affect all 46 residents who received meals from the kitchen. The facility census was 46. Findings include: Interview on 02/17/26 at 9:42 A.M. with Resident #126 revealed food is sometimes cold and believes it is due to being at the very end of the 100 Hall and last to be served. Residents Affected - Many Interview on 02/17/26 at 11:51 A.M. with Resident #32 revealed food is often cold or warm but not hot. Interview on 02/17/26 at 3:17 P.M. with Resident #19 revealed some of the food offered is lousy and that the hamburger provided was very overcooked and tough to bite into and eat. Observation revealed the last tray for the east wing room [ROOM NUMBER] was plated and placed on cart for service at 12:20 P.M. Further observation on 02/17/26 at 12:20 P.M. revealed a test tray was requested containing pizza casserole, green beans, and pumpkin mousse. The test tray was followed to the east wing. Further observation at 12:23 P.M. revealed two certified nursing aides (CNA)'s began to pass trays and drinks to residents who were dining in their rooms. Observation on 02/17/26 at 12:46 P.M. revealed the last tray for room [ROOM NUMBER] being served and then the test tray was sampled for food palatability for taste, texture and preferred food temperature. The green beans were not warm. The temperature was checked and verified by the Dietary Manager #138 at 120 degrees Fahrenheit and confirmed the green beans were not at appropriate temperature for palatability to eat as intended. This deficiency represents non-compliance investigated under Master Complaint Number 2733050. 366087 Page 3 of 6 366087 02/19/2026 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the spread of infection by not following proper hand hygiene during a dressing change. This affected one resident (#20) of three residents reviewed for wound care. In addition, the facility failed to follow proper infection surveillance to prevent the spread of urinary tract infections in January 2026. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 07/05/14. Diagnoses included amyotrophic lateral sclerosis, abnormalities of gait and mobility, muscle weakness, muscle wasting and atrophy, dysphagia, anxiety disorder, need for personal care assistance, moderate protein-calorie malnutrition, and pressure ulcer of sacral region, stage four. Residents Affected - Some A review of a Minimum Data Set (MDS) version 3.0 for Resident #20, dated 01/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 0 on a 0 to 15 scale. A score of 0 indicated the resident had severe problems with thinking and memory. The MDS also revealed the resident required supervision or touch assistance for eating, and was dependent for all other activities of daily living including bathing and personal hygiene. She was dependent for all transfers. Review of physician orders for Resident #20 revealed an order to cleanse peg tube stoma with NSS (normal saline solution), pat dry, apply drain sponge QD (daily) and PRN (as needed). The order was dated 02/18/26. On 02/18/26 at 1:50 P.M., observation of wound care for Resident #20 revealed proper hand hygiene was not followed. Observation revealed Registered Nurse (RN) #122 completed the dressing change for percutaneous endoscopic gastrostomy (PEG) tube. After removing the soiled dressing from the resident, using a gloved hand, RN #122 failed to remove soiled gloved, complete hand hygiene, and apply clean gloves. Instead, RN #122 removed the soiled dressing, cleansed the wound with soiled gloves, then removed gloves and revealed a second pair of gloves underneath. She then applied a clean dressing and performed hand hygiene. This was confirmed by RN #122 at the completion of the dressing change. On 02/18/26 at 2:02 P.M., an interview with RN #122 confirmed she failed to remove gloves, perform hand hygiene, and apply clean gloves after removing soiled dressing from Resident #20's PEG tube. Review of a undated facility policy titled Dressing Change-Clean revealed guidelines for the proper application of a dry, clean dressing. The policy revealed after removing a soiled dressing, the nurse should remove and dispose of gloves, then wash hands thoroughly. This policy was confirmed by Licensed Practical Nurse (LPN) #122 on 02/18/26 at 2:02 P.M Review of a undated facility policy titled Handwashing revealed it was the policy of the facility to maintain a high standard of hygiene in patient care through thorough handwashing procedures. All employees were to wash hands thoroughly with soap and running water before and after contact with resident bodily fluids, indwelling lines, resident equipment, soiled linen, when collecting specimens, or general cleaning. This policy was confirmed by LPN #122 during interview on 02/18/26 at 2:02 P.M. 2. Review of the facility infection control surveillance logs for the months of February 2026, January 2026, and December 2025 revealed the west wing (200 hall) had seven urinary tract infections 366087 Page 4 of 6 366087 02/19/2026 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (UTIs) in the month of January 2026, and the east wing (100 hall) had two UTIs. Further review revealed a facility total of three UTIs in December of 2025, none on the east wing and three on the west wing. Review of the infection surveillance log for January 2026 revealed three of the seven residents with diagnosed UTIs on the west wing did not have an identified organism listed for infection and referenced the diagnoses and orders for antibiotics were obtained from the local emergency rooms. Review of the infection surveillance room mapping for January 2026 revealed residents in rooms within close proximity of each other having UTI's including room [ROOM NUMBER], two residents in room [ROOM NUMBER], two residents in room [ROOM NUMBER], 208, and 210. Interview on 02/18/26 at 11:00 A.M. with Infection Preventionist (IP) #145 revealed she had just started her new position four weeks prior and was still learning the infection program at the facility. IP #145 further revealed she had not investigated or monitored for trends any infections from January or February 2026 yet and the regional nurse was going over it with her this week. IP #145 confirmed that there was an increase in January 2026 of UTI's on the west wing and that three of the residents did not have an organism listed and was entered as unknown from ER. Interview on 02/18/26 at 11:05 A.M. with registered nurse (RN) #401 revealed she was reviewing the infection surveillance logs for January and February 2026 for trends with the new infection preventionist this week and any follow-up needed would be discussed during the monthly quality assurance and performance improvement (QAPI) meeting and a plan would be made at that time. RN #401 also reported that she was new to the company and just started in her position in January of 2026. RN #401confirmed that there was an increase in January 2026 of UTI's on the west wing and that three of the residents did not have an organism listed and was entered as unknown from ER. Interview on 02/18/26 at 12:00 P.M. with the facility Administrator revealed the QAPI team meets quarterly and is due to meet at the end of February and the last meeting occurred for fourth quarter on 12/30/25. The Administrator further revealed that she started working at the facility as the Administrator in August of 2025 and the Director of Nursing (DON) just started at facility three days prior to the survey but had worked as a director of nursing at a sister facility for the past year. Review of the QAPI meeting minutes from 12/30/25 for fourth quarter of calendar year 2025 provided by the Administrator revealed seven nosocomial (facility acquired) infections in October, 12 nosocomial infections in November, and three in December of 2025. There were no problems or trends identified, or action plans taken or reference made as to why no action taken related to facility infections noted. This deficiency represents non-compliance investigated under Master Complaint Number 2733050 and Complaint Number 2638657. 366087 Page 5 of 6 366087 02/19/2026 Vista Center, The 100 Vista Drive Lisbon, OH 44432

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a comfortable and sanitary environment for residents. This had the potential to affect all residents living in the facility. The facility census was 46. Findings include:1. On 02/17/26 at 9:34 A.M., an observation of the west hallway between rooms [ROOM NUMBERS] revealed the hallway was full of equipment on both sides. Between room [ROOM NUMBER] and 215, there was a large covered laundry cart, a blue straight back chair, a dirty linen cart, and a housekeeping cart. These were blocking the handrails. Across the hall, there was a medication cart between room [ROOM NUMBER] and 214. There was also a nurse standing at the medication cart, preparing medications. The hallway was observed to be impassable for a wheelchair, blocked the handrail on both sides, and was impassable for someone with a walker as well. This was confirmed by the Administrator during interview on 02/17/26 at 9:40 A.M. On 02/17/26 at 9:50 A.M., an observation of an emergency exit in the east hall designated Mary's Place revealed the emergency exit door was blocked. There were two large wheelchairs, a bucket of bird food, and a vital sign machine blocking the path of egress out the emergency door. This was confirmed by Registered Nurse (RN) #104. Review of a facility policy titled Means of Egress, dated 10/10/17, revealed the facility would safeguard all residents, visitors and personnel by ensuring all emergency egress paths and exits were clear, unobstructed, completely accessible and illuminated from any residential area within the center to a public way. The policy further indicated all means of egress would be continuously maintained free of all obstructions or impediments to full instant use in case of fires or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access to, egress from or visibility. There would be no couches, chairs tables or other furniture in an exit access corridor. This policy was confirmed by the Administrator during interview on 02/17/26 at 9:40 A.M. An interview with the Administrator on 02/17/26 at 9:40 A.M. confirmed the west hallway had equipment, carts, and people on both sides of the hallway. She confirmed a wheelchair could not get through, nor could a resident with a walker, and the handrails were blocked on both sides of the hallway. This was the hallway leading to the main dining room. She confirmed the facility policy on safe paths of egress. On 02/19/26 at 12:17 P.M., an interview with a source that requested to remain anonymous revealed a resident had difficulty getting through the hallways with their wheelchair. There would always be carts of towels, beds, and all kinds of other stuff in the way and the resident could not get through. 2. On 02/18/26 at 8:20 A.M., observation of the main hallway revealed plaster missing from the corners of the walls. The main hallway, east hallway, and west hallway had a build-up of dirt along the floor and up the baseboards. There were large brown stains on multiple ceiling tiles in the main and west hallways, broken ceiling tiles in all three hallways, and one ceiling tile in the main hallway had a large brown stain with a black, mold-like appearance in the center. A portion of the ceiling in the main hallway, which contained a large light, had a water stain from around the light and across the ceiling. The three vents noted in the ceiling were coated with dirt and debris and two were rusty in appearance. There were balls of lint, dirt and debris hanging from between several of the ceiling tiles. This was confirmed by the Maintenance Director at 8:45 A.M. On 02/18/26 at 8:45 A.M., an interview with the Maintenance Director confirmed the dirty floors, broken and soiled ceiling tiles and air vents. He reported he had plenty of tiles to fix them, and had replaced the one with the moldy appearance several times, but the stain kept returning. This deficiency represents non-compliance investigated under Master Complaint Number 2733050 and Complaint Number 2638657. 366087 Page 6 of 6