Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Center Of Boardman during CMS and state inspections, most recent first.
Expired Hydrion test strips were found at the three-sink manual dishwashing area during a kitchen tour, and an FNS staff member verified the expiration date. Facility policy required sanitizer strength to be checked and recorded before each use, but the available test strips were past expiration. The issue affected food service operations for residents receiving meals from the kitchen, including a resident who was NPO.
Unsanitary Dumpster Area: The facility failed to maintain a sanitary garbage storage area when an observation found approximately six pairs of used vinyl medical gloves scattered around the dumpster. The dumpster lid and side slide door were open, and an LTC dietary staff member verified the findings. Facility policy required the dumpster to have a tight-fitting lid and/or slide door and to be covered at all times.
The facility failed to maintain infection control and sanitation during medication administration, isolation precautions, blood glucose monitoring, dining, and laundry operations. An RN did not perform hand hygiene between administering medications to two residents, a resident on contact isolation had PPE and soiled linen stored outside the room, an LPN cleaned a glucometer with a wipe that did not contain bleach, a resident’s meal tray was placed beside a urinal containing urine, and the laundry area was observed dirty, cluttered, and containing soiled items and debris.
Failure to provide proper grooming and facial hair removal for a dependent resident. A resident with severe cognitive impairment, MS, vascular dementia, and total ADL dependence was observed with excessive chin hair on multiple occasions. CNAs confirmed the facial hair, stated shaving was done only twice weekly during showers, and one CNA said she never shaved the resident and did not know the expected frequency. Facility policy listed removal of women's facial hair as part of typical personal hygiene.
A resident receiving O2 therapy had nasal cannula tubing that was not changed weekly as ordered. The resident had COPD and respiratory failure diagnoses, was cognitively intact, and was observed seated in a wheelchair on 4 L/min via NC with tubing dated well beyond the weekly change interval. An RN confirmed the date and stated the tubing was to be changed weekly; the facility policy also stated the nasal cannula should be changed weekly and as needed.
Medications Left at Bedside Without Authorization: A resident with COPD had Advair ordered, but the record contained no order for bedside storage or self-administration, and no self-administration assessment or care plan interventions were documented. During observation, two inhalers were found on the resident’s over-the-bed table, and the ADON confirmed they should not have been left there.
Call Light Not Within Reach: A resident with dementia, muscle weakness, and moderate cognitive impairment had the call light activation button placed on top of a mini refrigerator about three feet from the bed and underneath papers. The resident was dependent for toileting and showers, and the care plan identified the resident as at risk for falls with an intervention to keep commonly used items, including the call light, within easy reach.
Resident room not kept in good repair. A resident with DM1, immunodeficiency, and difficulty walking was observed in a room with a large gouge in the wall, dirt and debris buildup along the baseboard and behind the door, a missing baseboard behind one bed, and another baseboard coming away from the wall. The MDS showed the resident was cognitively intact, and the MD verified the disrepair but was unsure when the damage occurred.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not have an RN present for eight consecutive hours on one day, despite meeting overall direct care staffing requirements. This lapse in RN coverage was confirmed by the Human Resources Manager and had the potential to affect all residents.
The facility did not report or thoroughly investigate multiple allegations of resident-to-resident abuse, including an incident where a resident with cognitive impairment sustained facial burns from hot coffee thrown by another resident, and another case involving verbal and alleged physical abuse between roommates. Staff and administration confirmed these incidents were not reported to the state agency, and responsible parties were not notified, contrary to facility policy.
The facility did not thoroughly investigate or report multiple allegations of resident-to-resident abuse, including an incident where a resident sustained facial burns from hot coffee thrown by another resident and another case involving verbal and alleged physical abuse between roommates. Staff failed to notify responsible parties and relied solely on resident statements, even when cognitive impairment was present, contrary to facility policy requiring thorough investigation and reporting.
A pest control deficiency was identified when bed bugs were found in several resident rooms and common areas on a secured unit. Staff and an LPN reported discovering bed bugs about a week before treatment was initiated, and pest control services confirmed only chemical treatment had been performed, with no heat treatment completed. The infestation affected multiple residents and required disposal of infested furniture.
Multiple residents who were dependent on staff for ADLs did not receive timely incontinence care or scheduled showers as required by their care plans and facility policy. Staff failed to provide incontinence care every two hours for a resident with severe cognitive impairment, did not use proper PPE, and did not maintain proper hygiene during care. Several residents missed numerous scheduled showers, with staff and residents confirming that showers were often skipped due to time constraints, and complaints were received from residents and families.
Two CNAs provided incontinence care to a resident on Enhanced Barrier Precautions without wearing the required gown and gloves, despite clear signage and available PPE, in violation of facility policy for infection control.
The facility failed to provide scheduled therapeutic activities, particularly during weekends and evenings, affecting all residents. Observations and interviews revealed a lack of activities after 3:00 P.M. for Secure Unit A and after 4:00 P.M. for Unit B/C, with understaffing and reliance on a counseling service not responsible for activities. Residents expressed boredom, and scheduled activities were not conducted due to staff shortages and lack of materials.
The facility did not have a qualified Activity Director overseeing the activity department, affecting all 50 residents. The former Activity Director's file lacked necessary certification, and the facility relied on [NAME] Counseling staff, who were not certified in activities, to provide activities. The facility's policy required an Activities Director to plan and organize activities, but this was not being met.
The facility did not ensure that each STNA received the required twelve hours of annual in-service education, affecting all residents. A review of a personnel file revealed that an STNA hired in 2022 had completed only one training session on corporate compliance, with zero hours of training out of 20.83 assigned. Various trainings were assigned but not attempted. The HR Manager confirmed the lack of completed training and did not have a policy for in-service training.
The facility did not ensure the dietary manager was qualified, affecting meal services for 50 residents. The manager, promoted from a cook position, lacked formal training and certification. A dietitian was only present part-time, focusing on clinical work rather than kitchen oversight. The administrator confirmed the manager's lack of qualifications.
The facility failed to serve food at a palatable and safe temperature, affecting residents' meal satisfaction. Observations and interviews revealed that food temperatures dropped significantly by the time meals were served, leading to complaints about cold and unappetizing food. The facility lacked a policy on food palatability, and the issue had the potential to affect all residents receiving meals.
The facility failed to maintain proper food storage and sanitation standards, as observed during a kitchen inspection. Issues included improperly stored and labeled food items, dirty utensils, and unsanitary conditions in the kitchen and storage areas. These deficiencies were verified by the dietary manager, indicating non-compliance with food safety policies.
The facility failed to manage resources effectively, impacting resident care. QAPI meetings lacked required medical director attendance, and no evidence of meetings existed before April 2024. The facility lacked a certified Activities Director, relying on uncertified external counselors for activities, leading to insufficient resident engagement, especially on weekends and after 3:00 P.M.
The facility did not conduct quarterly QAPI meetings and failed to ensure the medical director's participation. Attendance records showed the medical director was absent from meetings held from April to September 2024, and there was no evidence of meetings before April 2024. The Administrator confirmed these deficiencies, potentially affecting all 50 residents.
The facility failed to follow Enhanced Barrier Precautions for a resident with a gastric tube, as a CNA did not wear a gown during incontinence care. Additionally, the facility did not complete annual TB screenings for several employees, as required by their policy. These deficiencies had the potential to affect all 50 residents.
The facility did not maintain a safe and comfortable environment, as evidenced by a resident's bed with a broken side rail, an open corroded hole in the ceiling, sharp edges in the 100 hall, exposed sharp wall pieces, and an unsecured floor strip creating a tripping hazard. These issues were confirmed by the Maintenance Director.
The facility failed to maintain a surety bond sufficient to cover all resident personal funds, affecting 20 residents. The total amount in resident fund accounts exceeded the bond amount, which was initially set at $20,000 and later adjusted to $120,000. Facility policy required the bond to match the total resident funds.
A facility failed to ensure consistent documentation of a resident's advance directives, leading to a discrepancy between the resident's DNR Comfort Care status and their expressed wish to be Full Code. Despite the resident's clear communication and updated physician orders, the outdated DNR form remained in the electronic record, causing confusion among staff about which code status to follow. Interviews revealed a lack of clear policy and training on verifying code status, potentially affecting all residents.
A resident with a history of aggression threw hot coffee on his roommate, who was unable to move independently, causing the roommate to feel scared and perceive the incident as abusive. The facility failed to report this resident-to-resident abuse to the state agency within the required 24-hour timeframe, as the Administrator did not initially view the incident as abuse.
The facility failed to ensure accurate care plans for two residents, affecting potential care for all 50 residents. One resident's care plan omitted Depakote medication and inaccurately listed their code status. Another resident lacked a care plan for anti-coagulant therapy despite being on such medication and refusing lab work. These deficiencies were confirmed by facility staff and violated the facility's care planning policy.
The facility failed to ensure timely and accurate care plans for two residents, affecting their discharge plans and care status. One resident's care plan was not updated to reflect a change from short-term to LTC, and another's care plan inaccurately indicated a discharge home despite being LTC. Staffing changes and lack of adherence to facility policy contributed to these deficiencies.
A resident with hemiplegia and hemiparesis, requiring assistance for oral hygiene, did not receive oral care since admission, as confirmed by observations and interviews. Despite a physician's order for oral care every shift, the resident's teeth showed food and plaque buildup, and no oral care supplies were found in the room. The DON was informed of the deficiency, which contradicted the facility's policy to provide personal care according to the resident's plan.
The facility failed to ensure timely and accurate weight monitoring for residents, leading to deficiencies in nutritional health management. A resident with PTSD and bipolar disorder had inconsistent weight records, with no weight recorded for a month and an inaccurate weight noted later. Another resident with pulmonary disease experienced significant weight loss without proper reweighing, and a third resident with chronic bronchitis had fluctuating weights due to edema, with no reweighs conducted. The facility did not adhere to its policy requiring monthly weights and reweighs for significant variances.
A facility failed to provide trauma-informed care for a resident with PTSD, bipolar disorder, and major depression. Despite the resident's identified trauma triggers, there was no care plan or staff training to manage these issues. Interviews revealed staff were unaware of the resident's PTSD and potential triggers, and observations showed the resident exhibited behaviors like pacing and verbal aggression. The facility's policy required care planning and staff education, which were not implemented.
The facility failed to conduct an AIMS test for a resident on Olanzapine and did not monitor Depakote levels for another resident. Despite policy requirements, the AIMS test was not performed for a resident with severe psychotic symptoms, and no lab orders were in place for monitoring Depakote levels in a resident with dementia. The DON confirmed these oversights, indicating a lack of adherence to monitoring protocols.
Expired Sanitizer Test Strips at Dishwashing Area
Penalty
Summary
The facility failed to have unexpired Hydrion test strips available at the three-sink manual dish washing area to test proper sanitization levels. During the initial kitchen tour, Hydrion test strips were observed with an expiration date of 11/01/25, and Dietary staff #513 verified that expiration date at the time of the observation. The report identified that this area was used for manual ware washing and that proper test strips should be readily available. Facility policies titled Manual Ware Washing and 3 Compartment Sink Sanitizer Strength Record stated that manually washed pots, pans, and cooking utensils shall be sanitized using a wash, rinse, and sanitize process, and that sanitizer concentration should be checked and recorded prior to each use. The policies further stated that sanitizer strength in the third tank of the three-compartment sink shall be monitored prior to each use and recorded by food and nutrition services staff. The facility census was 46, and the report noted that 45 residents received food from the kitchen, including one resident identified by the facility as receiving nothing by mouth.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary garbage storage area. During an observation of the outside dumpster area, approximately six pairs of used vinyl medical gloves were found scattered on the ground around the dumpster. The dumpster lid was open and the side slide door was open. Dietary staff member #513 verified these findings at the time of the observation. A review of the facility policy titled Garbage Removal and Dumpster, dated 12/21/21, stated that garbage can attract pests and contaminate food, equipment, and utensils if not handled correctly and that the garbage dumpster must have a tight-fitting lid and/or slide door and be covered at all times.
Infection Control and Sanitation Failures
Penalty
Summary
The facility failed to maintain infection prevention practices during medication administration when an RN administered Lorazepam to one resident and then proceeded to another resident’s room without performing hand hygiene. The same RN later administered Lurasidone to the second resident, and when asked to perform hand hygiene before continuing medication pass, she acknowledged she had not performed hand hygiene before or after administering medications to either resident. The residents involved had multiple chronic conditions, including respiratory failure, COPD, kidney disease, dysphagia, encephalopathy, epilepsy, bipolar disorder, depression, and other diagnoses listed in their records. The facility also failed to properly manage contact isolation precautions for a resident with MRSA of the right foot. Outside the resident’s room, there was a sign indicating contact isolation precautions, but two large boxes lined with yellow biohazard bags were placed outside the room, one containing discarded PPE and the other soiled linen. The RN observing the area was unsure where the boxes belonged, and another RN stated the boxes should have been placed inside the resident’s room per facility policy. CDC guidance reviewed during the survey stated that discarded used PPE and soiled linens should be stored inside the patient’s room in a plastic bag labeled bio-hazardous material. The facility further failed to clean a glucometer appropriately after blood glucose testing for a resident with diabetes, heart failure, respiratory failure, kidney failure, and other diagnoses. After obtaining the resident’s blood sugar and administering Lispro insulin, the LPN cleaned the glucometer with a sanitized disposable wipe that did not contain bleach. The LPN stated she knew a bleach-containing sanitizing wipe should have been used, but none were available in the medication cart. The facility policy required a disposable sanitizing wipe with bleach to clean the glucometer after each use. In addition, a resident eating breakfast was served a meal tray placed beside a urinal that was two-thirds full of dark yellow urine on the over-bed table. The resident stated he had used the urinal before staff served the meal, and the CNA agreed she had delivered the tray and should have moved the urinal before placing the breakfast beside it. The survey also found the laundry area was dirty and disorganized, with lint, dirt, debris, stained floors, soiled linens, stacked pillows, missing or loose tiles, a leaking washing machine hose, and a utility sink containing feces-soiled linens in a bucket. The laundry assistant stated she was the only staff member working in the laundry room and did not have time to clean the laundry rooms as needed.
Failure to Provide Proper Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to ensure proper grooming for Resident #53 by not removing facial hair as part of daily hygiene care. Resident #53 was admitted on 07/20/10 with diagnoses including Multiple Sclerosis, bipolar disorder, dysphagia, muscle wasting and atrophy, vascular dementia, lack of coordination, hypertensive retinopathy, corneal deformity, and congenital malformation of the eye. The MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and the resident was dependent on staff for all ADLs and mobility, requiring a Hoyer lift for all transfers. The care plan stated the resident was totally dependent with ADLs and all care, with staff to assist with daily hygiene. During observation on 02/17/26 and again on 02/18/26, the resident was noted to have an excessive amount of facial hair on the chin. On 02/18/26, CNA #535 confirmed the facial hair and stated staff shaved the resident twice per week during showers but did not shave her more often because they could not keep up with how quickly it grew. On 02/19/26, CNA #548 also confirmed the excessive chin hair and stated she never shaved the resident and did not know how often the resident was supposed to be shaved. The facility policy titled Resident Care stated that typical personal hygiene for a resident included removal of women's facial hair.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to change nasal cannula tubing weekly for a resident receiving oxygen therapy. Resident #1 was admitted with diagnoses including acute respiratory failure with hypoxia, COPD, and acute respiratory failure. The resident had an order to change oxygen tubing/cannula/mask every week on every Saturday and an order for oxygen at 4 liters per minute via nasal cannula as needed to keep oxygen saturation above 90%. The annual MDS indicated the resident was cognitively intact and that oxygen therapy was in use, and the care plan identified an alteration in respiratory function with oxygen use as an intervention. During observation on 02/17/26 at 11:26 A.M., Resident #1 was seated in a wheelchair receiving oxygen via nasal cannula at 4 liters per minute. The nasal cannula was dated 01/25/26, and RN #537 verified the date at the time of the observation. RN #537 stated the oxygen tubing was to be changed weekly. The facility policy titled Nasal Cannula stated the nasal cannula is recommended to be changed weekly and as needed.
Medications Left at Bedside Without Authorization
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for one resident. Resident #33 was admitted with a diagnosis of COPD and had an order for Advair Diskus inhalation powder 250/50, inhale one puff two times a day for COPD. The medical record did not contain any order for the medication to be left at the bedside, any order for the resident to self-administer Advair, or any order for an Advair aerosol inhaler. The quarterly MDS assessment showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Review of the record also found no medication self-administration assessment and no care plan interventions related to self-administration. During observation, an Advair Diskus powder inhaler and an Advair aerosol inhaler were seen on the resident’s over-the-bed table, and the ADON verified both inhalers were there. The ADON stated the inhalers should not have been left at the bedside and that the resident did not have an order to self-administer medications. Facility policy stated medications are to be stored properly and locked when not in use or attended by authorized persons, and that residents may self-administer medications only when specifically authorized.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #11's call light activation button was within reach. Resident #11 was admitted on 04/22/23 and had diagnoses including dementia, unspecified severity without behavioral disturbance, need for assistance with personal care, and muscle weakness. The care plan dated 12/16/25 identified the resident as at risk for falls and included an intervention to keep commonly used articles within easy reach, including the call light. The quarterly MDS assessment showed a BIMS score of nine, indicating moderate cognitive impairment, and the resident was dependent for toileting and showers. During an observation on 02/17/26 at 9:56 A.M., Resident #11 was lying in bed and the call light activation button was found on top of a mini refrigerator to the left of the bed, underneath several papers, approximately three feet from the bedside. CNA #562 verified the placement at the time of the observation. The facility policy titled Call Light Answering stated that the facility is to be adequately equipped with a call light at each resident bedside, toilet, and bathing facility, and that staff will ensure the call light is within reach of each resident and secured as needed.
Resident Room Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure Resident #9's room was in good repair. Resident #9 was admitted on 02/06/25 and had diagnoses including type one diabetes mellitus, immunodeficiency due to conditions classified elsewhere, and difficulty walking. The quarterly MDS 3.0 assessment showed a BIMS score of 14, indicating the resident was cognitively intact, and the care plan dated 12/05/26 contained no indication that the resident refused housekeeping or maintenance services. During observation on 02/18/26 at 8:35 A.M., Resident #9's room was found in general disrepair, including a large deep gouge in the wall between the sink and bathroom extending approximately three feet above the baseboard, visible buildup of dirt and debris along the baseboard and behind the entrance door, a missing baseboard behind bed A, and a baseboard at the entrance door coming away from the wall. The Maintenance Director verified these findings and stated he was not sure when the wall gouge or missing baseboard occurred.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for eight consecutive hours on a specific day, as required by regulations. Record review of the nursing services staffing schedule and staffing tool for the period of 06/22/25 to 06/27/25 showed that, although the facility met or exceeded the minimum staffing requirement of 2.5 hours of direct care per resident per day, there was no RN on staff for eight consecutive hours on 06/25/25. During an interview, the Human Resources Manager confirmed that the facility was staffed based on acuity and census numbers, with one nurse and one aide per unit, and acknowledged that the required RN coverage was not met on the identified day. The Director of Nursing (DON) was full-time, but the facility did not have an RN present for the required duration on that day. This deficiency was identified during the investigation of a specific complaint and had the potential to affect all residents in the facility.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency as required, affecting four residents out of five reviewed for abuse. In one incident, a resident with impaired cognition sustained facial burns after another resident threw coffee at him. The incident was documented in the medical record, and the resident was treated with Silvadene cream, but there was no documentation regarding how the burns occurred, and the event was not reported to the state agency. Interviews with staff and administration confirmed that the incident was not reported, and the responsible parties for the injured resident were not notified. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were informed by a visitor about physical abuse. The staff assessed the resident and questioned both parties, but when both denied the incident, no further investigation was conducted, and the event was not reported to the state agency. The administration acknowledged that the resident who was allegedly abused had cognitive impairment and that further investigation and reporting should have occurred. Review of facility policy indicated that all allegations of abuse, neglect, or misappropriation should be reported to the state agency and thoroughly investigated. However, the facility did not submit self-reported incidents for these events and did not conduct thorough investigations as required by policy. This deficiency was identified during the investigation of a specific complaint.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated and reported as required. In one incident, a resident with impaired cognition sustained facial burns after another resident threw coffee at him. The incident was documented in the medical record, and the resident was treated with Silvadene cream, but there was no documentation regarding how the burns occurred. The event was not reported to the state agency, and the responsible parties were not notified. Interviews with staff confirmed that the incident was not thoroughly investigated or reported as required by facility policy. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were later informed by a visitor that physical abuse may have occurred. The staff assessed the resident and questioned both parties, but when both denied the incident, no further investigation was conducted, and the event was not reported to the state agency. The resident who was allegedly abused had severely impaired cognition, which was not taken into account during the investigation. Review of facility policy indicated that all allegations of abuse should be reported and thoroughly investigated. However, in these cases, the facility did not follow its own policy, as multiple incidents involving resident-to-resident abuse were neither reported to the state agency nor thoroughly investigated. This deficiency affected four residents out of five reviewed for abuse, as documented in the survey findings.
Failure to Maintain Effective Pest Control Program Resulting in Bed Bug Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of bed bugs in multiple resident rooms and common areas on the secured A unit. Observations confirmed bed bugs in the rooms of several residents, and interviews with staff revealed that bed bugs had been found approximately one week prior to treatment. Staff reported capturing bed bugs, notifying maintenance and the DON, and following internal procedures such as bagging resident clothing and cleaning affected areas. However, treatment for the infestation was not initiated until the day of the survey, despite earlier detection. Further interviews indicated that bed bugs were also found on a staff member and in the dining/lounge area, leading to the disposal of infested furniture. The pest control contractor confirmed that only a chemical treatment was performed, and no heat treatment, which was identified as necessary to stop the infestation, had been completed at the time of the survey. The deficiency affected 19 residents on the secured unit and was identified during the investigation of specific complaint numbers.
Failure to Provide Timely Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide timely incontinence care and scheduled showers for multiple residents who were dependent on staff for activities of daily living (ADLs). One resident with severe cognitive impairment and total dependence for ADLs was found to have not received incontinence care for three and a half hours, despite care plans requiring assistance every two hours and as needed. During observation, staff did not use required personal protective equipment (PPE) while providing care, and soiled wipes were placed on the resident's bed instead of being disposed of properly. The resident was found to be soaked through their brief and incontinence pad, with a strong odor of urine present, and the fitted sheet was not changed after contamination. Several residents did not receive showers according to their scheduled frequency. One resident, dependent on staff for showers and other ADLs, received only six out of thirty scheduled showers. Another resident, also dependent on staff for personal care and showers, received only one shower in February, eight in March, and seven in April, despite being scheduled for three showers per week. Two additional residents received only two and four showers, respectively, out of seventeen scheduled sessions. Documentation confirmed these missed showers, and interviews with staff and residents corroborated that showers were often not completed as scheduled, with some residents and families voicing complaints. Facility policy required that residents be interviewed about their bathing preferences upon admission and that these preferences be reviewed quarterly. Staff were expected to assist with daily hygiene and showers per policy. However, interviews with CNAs, LPNs, and RNs revealed that showers were frequently missed due to time constraints, and staff only completed assigned showers if time allowed. The facility's leadership confirmed the discrepancies in shower provision and acknowledged the lack of documentation for missed showers.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to ensure effective infection control techniques were practiced during incontinence care for a resident who was under Enhanced Barrier Precautions (EBP). The resident, who had multiple diagnoses including epilepsy, muscle weakness, hemiplegia, aphasia, and was dependent on staff for all activities of daily living, was ordered to be on EBP due to wounds and the presence of a PEG tube. Facility policy required staff to wear gowns and gloves during high-contact care activities for residents on EBP, with proper signage and PPE available in the resident's room. During an observation, two CNAs provided incontinence care to the resident without donning the required gown and gloves, despite being aware of the EBP status, signage, and availability of PPE. Both CNAs confirmed in interviews that they should have worn the appropriate PPE but did not do so. Review of facility policy confirmed the requirement for gown and glove use during such care activities for residents on EBP.
Failure to Provide Scheduled Therapeutic Activities
Penalty
Summary
The facility failed to provide therapeutic activities as scheduled, particularly during weekends and evenings, affecting all 50 residents. Observations and interviews revealed that no activities were scheduled after 3:00 P.M. for Secure Unit A in October and after 4:00 P.M. in September. Unit B/C had no activities scheduled after 3:00 P.M., except on Wednesdays. The activity department was understaffed, with no activity aid scheduled on several days in September and October. The former Activities Director and an Activities Aid had left, and the facility was relying on a counseling service that was not responsible for activities. Interviews with residents and staff highlighted the lack of activities, with residents expressing boredom and a lack of engagement. The Director of Nursing confirmed the absence of an Activity Director and the reliance on a counseling service for activities. Observations showed that scheduled activities were not conducted, with residents left unattended or watching television without engagement. Staff shortages further hindered the ability to provide planned activities, and necessary materials for activities were not available. The facility's policy required the Activities Director to plan and organize activities to meet residents' interests and preferences. However, the absence of a qualified Activities Director and insufficient staffing led to a failure in implementing the policy. The facility did not notify residents of changes in the activity schedule or offer alternatives, contributing to the deficiency in meeting residents' needs for therapeutic activities.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to ensure that a qualified Activity Director was overseeing the activity department, affecting all 50 residents. The job description for the Activity Director required a qualified therapeutic recreation specialist or an activities professional licensed by the state and eligible for certification. However, the personnel file for the former Activity Director, who was hired on 05/16/23 and last worked on 09/16/24, lacked certification from the Activity Directors Network. Interviews revealed that there had been no Activity Director for the past month, and the facility was relying on a social worker and two counselors from [NAME] Counseling to provide activities, despite them not being certified in activities. The Behavioral Health Service Agreement with [NAME] Counseling did not include responsibility for ensuring activities were provided to residents. Interviews with [NAME] Counseling staff confirmed that they were not the activities department and were only providing activities as part of their counseling sessions. The facility had only one activity aid who worked every other weekend, and nursing staff were tasked with providing activities on weekends when the aid was not present. The facility's policy stated that the Activities Director should plan and organize activities to meet residents' interests and preferences, but this was not being fulfilled due to the lack of a qualified director.
Failure to Ensure Required Annual In-Service Education for STNAs
Penalty
Summary
The facility failed to ensure that each state tested nurse aide (STNA) received the required twelve hours of annual in-service education, potentially affecting all residents in the facility with a census of 50. A review of the personnel file for STNA #551, who was hired on 02/02/22, revealed that she had completed only one training session on corporate compliance on 06/04/24. This training did not specify its duration, and the report indicated that STNA #551 had zero hours of training out of the 20.83 hours assigned. The training record showed that she was assigned various trainings, including abuse, dementia care, infection control, fall management, fire safety, resident rights, and elopement prevention, but these were marked as not attempted. An interview with Human Resource Manager #525 confirmed that STNA #551 had not completed the required annual training. The HR Manager acknowledged that she assigns the training but cannot compel the aides to complete it, as evidenced by the report sheet showing uncompleted trainings. Additionally, the HR Manager did not have a policy regarding in-service training for STNAs.
Unqualified Dietary Manager in Facility
Penalty
Summary
The facility failed to ensure that the dietary manager was qualified to oversee dietary service operations, potentially affecting all 50 residents receiving meals from the kitchen. The dietary manager, who was promoted from a cook position in May 2024, lacked formal certified dietary manager training and had not completed the SERV Safe course. Interviews revealed that there was no full-time dietitian on-site, with a dietitian only scheduled to be present one day a week for six hours and two hours remotely, focusing on clinical work rather than kitchen oversight. The facility's administrator confirmed that the dietary manager did not meet the required qualifications for the position and was not certified, although efforts were being made to obtain certification.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency was observed during interviews and a test tray observation. Resident #15 reported that if his tray was served last, the food was often cold, which affected the quality and nourishment of the meals. Resident #196 also expressed dissatisfaction with the taste and temperature of the food, leading his family to bring in outside food. An observation of the lunch tray line revealed that while the starting temperatures of the food were within safe limits, by the time the food was served, the temperatures had dropped significantly, rendering the food lukewarm and unpalatable. The test tray observation conducted with the Dietary Manager showed that the food temperatures had fallen into the danger zone for bacterial growth, as defined by the 2013 Federal Food Code. The facility did not provide a policy related to the palatability of food, and interviews with residents and a registered nurse confirmed that complaints about cold food were common. The facility census was 50, and the deficiency had the potential to affect all residents receiving meals from the facility kitchen.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and handled in a manner that prevents contamination and foodborne illness, as observed during a kitchen inspection. During the initial tour, dried noodles and chicken were found in the empty wash bay of a three-bay sink, and noodles and white beans were observed in the dishwasher drain. The dry storage area contained dented cans of food, an opened and undated bag of pancake mix, and a case of bananas placed directly on the floor. Additionally, a plastic drawer under the preparation counter was found to contain dirty utensils, and the walk-in refrigerator had an unwrapped piece of cake. The walk-in freezer had ice buildup on the floor and icicles hanging from the fan. A black substance was noted on a paper towel after wiping the ice distribution area of the ice machine. A follow-up observation revealed further issues, including opened, undated, and unlabeled garlic bread slices and mini meatballs in the freezer, as well as an opened and unlabeled 50-pound bag of rice in the dry storage area. The facility's policies on food storage and safety, which require proper labeling, dating, and storage of food items, were not adhered to. These deficiencies were verified by the dietary manager during the observations, indicating a lack of compliance with established food safety and sanitation standards.
Deficiency in Resource Management and Activity Program
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the quality of care for its residents. The Quality Assurance Performance Improvement (QAPI) committee meetings were not conducted with the required attendance of the medical director or a designee, and there was no evidence of such meetings prior to April 2024. This lack of oversight and documentation was confirmed by the Administrator, who assumed the position in April 2024. Additionally, the facility did not employ a qualified director of activities, as the former Activities Director was not certified, and there was no Activities Director for the past month. The facility relied on a social worker and counselors from an external counseling service to provide activities, but these individuals were not certified in activities and did not work on weekends or past 4:00 P.M. This resulted in a lack of structured activities for residents, particularly on weekends and after 3:00 P.M. on weekdays. Observations and interviews revealed that scheduled activities were not being conducted as planned. Residents reported a lack of engagement and boredom due to the absence of activities, and staff confirmed that activities were not always provided due to staffing shortages. The activity calendars showed no scheduled activities after certain hours, and observations confirmed that planned activities were not taking place, with residents left unengaged and without the necessary resources to participate in scheduled activities.
Failure to Conduct QAPI Meetings and Ensure Medical Director Participation
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and did not ensure the participation of the designated medical director in these meetings. This deficiency was identified through a review of attendance signature sheets, which showed that the medical director was not present at any of the QAPI meetings held on several dates from April to September 2024. Additionally, there was no evidence of any QAPI meetings being conducted prior to April 2024. An interview with the Administrator confirmed the absence of the medical director's attendance and the lack of QAPI meetings before April 2024, when the current Administrator assumed her role. This failure had the potential to affect all residents, with the facility census being 50.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident identified as being at risk for infection due to the presence of a gastric tube and total parenteral nutrition (TPN). During an observation, a Certified Nurse Assistant (CNA) provided incontinence care to the resident without wearing a gown, despite the facility's policy requiring gown and glove use during high-contact resident care activities. This was confirmed by both the CNA and the infection control nurse, who acknowledged that the resident was on EBP and that a gown should have been worn. Additionally, the facility did not complete annual tuberculosis (TB) signs and symptoms screenings for several employees as required by their TB risk assessment and policy. Personnel files for a State Tested Nursing Assistant (STNA) and a Licensed Practical Nurse (LPN) revealed that annual TB screenings were not conducted within the last year. Interviews with the Human Resource (HR) Manager and the Director of Nursing confirmed the absence of these screenings, despite the facility's policy stating that employees should receive annual TB screenings. The facility's failure to implement these infection prevention and control measures had the potential to affect all 50 residents. The facility's TB risk assessment indicated a low risk for TB, yet it required baseline skin testing and annual symptom screenings for healthcare workers. The HR Manager admitted to not tracking or completing these screenings, and the Director of Nursing assumed HR was responsible for them, indicating a lack of clarity in roles and responsibilities regarding TB screening compliance.
Unsafe and Uncomfortable Environment in Facility
Penalty
Summary
The facility failed to ensure a safe, functional, and comfortable environment for all residents, as observed during a survey. A resident's bed had a side rail that was breaking off and could be pulled away from the bed, posing a safety risk. Additionally, a corroded hole in the ceiling of the 100 hall was left open due to water leakage from the roof, which the Maintenance Director acknowledged but lacked materials to repair. This hole was large enough to allow potential pests to enter resident-occupied areas. Furthermore, the 100 hall had a hole with sharp edges that could cause injury to residents passing by, and a ripped corner molding in the transition from C hall to B hall exposed a sharp piece of the wall. Lastly, a floor strip leading into a resident's room was not secured, creating a tripping hazard. These deficiencies were verified by the Maintenance Director during the observation.
Inadequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to maintain a surety bond large enough to cover the total amount of money in all resident personal funds accounts, which had the potential to affect 20 residents. A review of the resident fund accounts on a specific date revealed a total amount of $98,931.82, while one resident had deposited $101,801.07 earlier in the year and had $91,442.68 in their account on the same date. An email from the Business Office Manager indicated that the active surety bond did not cover the amount in resident fund accounts. The surety bond, effective from a certain date, was initially for $20,000, but was later changed to $120,000 and backdated. The facility's policy required the bond to be at least equal to the total amount of residents' funds as of the most recent quarter.
Inconsistent Advance Directives and Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directives in the medical record and physician orders were consistent, leading to a discrepancy in the resident's code status. The resident, who had intact cognition, initially had a Do Not Resuscitate (DNR) Comfort Care status documented by a nurse practitioner. However, during a quarterly care plan meeting, the resident expressed a desire to change his code status to Full Code, which was documented in the care plan and physician orders. Despite this change, the DNR form remained in the miscellaneous section of the electronic medical record, creating a conflict between the documented code statuses. Interviews with facility staff revealed a lack of clarity and training regarding which code status to follow in the event of an emergency. A Licensed Practical Nurse (LPN) indicated she would rely on the state DNR form found in the miscellaneous section, even if it conflicted with the physician's orders. The Director of Nursing (DON) confirmed the inconsistency between the physician's order and the electronic record and acknowledged the absence of a clear policy or training for staff on how to verify a resident's code status. This deficiency had the potential to affect all residents in the facility.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within 24 hours to the state agency. This incident involved Resident #38, who threw a cup of hot coffee on Resident #144. Resident #38 had a history of behavior problems, including verbal outbursts and physical aggression, and was diagnosed with psychosis, dementia, and malignant neoplasm of the colon. At the time of the incident, Resident #38 approached a nurse and admitted to throwing coffee on his roommate, Resident #144, who was in bed and unable to move independently. Resident #144, diagnosed with schizoaffective disorder, depression, anxiety, and unspecified psychosis, was dependent on staff for transfers and had moderately impaired cognition. After the incident, Resident #144 expressed feeling scared and described the event as abusive, noting that the hot coffee burned when it was thrown on him, although no redness was observed on his skin. Despite Resident #144's perception of the incident as abusive, the facility's Administrator did not initially report the incident as abuse, as she did not view it as such. The Director of Nursing interviewed Resident #38, who mentioned the word 'revenge' but could not explain his actions. The facility increased monitoring of Resident #38 and sent him to a psychiatric hospital for evaluation. However, the facility did not file a self-reported incident (SRI) with the Ohio Department of Health within the required 24-hour timeframe. The report was only filed after surveyor questioning, which highlighted the facility's failure to adhere to its policy on reporting allegations of abuse promptly.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure accurate care plans were in place for two residents, which had the potential to affect all 50 residents residing in the facility. For Resident #19, the care plan did not include the medication Depakote, which was prescribed for behaviors related to dementia with behavioral disturbances. Additionally, the care plan inaccurately listed the resident as Full Code status instead of Do Not Resuscitate Comfort Care Arrest (DNRCCA) as ordered. The absence of Depakote monitoring in the care plan was confirmed by the Regional MDS Nurse/RN, and the facility's policy on care planning was not adhered to, as it requires the interdisciplinary team to review and update care plans quarterly and annually. For Resident #148, the facility did not have a care plan in place for anti-coagulant therapy, despite the resident being on Coumadin and later switched to Eliquis due to refusal of PT/INR lab work. The resident had diagnoses including hypertension, diabetes, and atrial fibrillation, and was dependent on staff for most activities of daily living. The lack of a care plan for monitoring adverse side effects and medication management was verified by both the Regional MDS Nurse/RN and the Director of Nursing. The facility's policy mandates the creation of a care plan that includes measurable goals and specific interventions, which was not followed in this case.
Failure to Ensure Timely and Accurate Care Plans
Penalty
Summary
The facility failed to ensure timely and accurate care plans for two residents, which had the potential to affect all 50 residents residing in the facility. For Resident #34, the medical record indicated an admission with diagnoses including atrial fibrillation, multiple sclerosis, diabetes mellitus type two, and morbid obesity. Despite a change in discharge plans from short-term to long-term care during a care conference, the care plan dated later still indicated a discharge home. Interviews revealed that the responsibility for long-term care plan meetings was not being fulfilled due to staffing changes, and the Director of Nursing confirmed that a care plan meeting should have occurred in September. Similarly, for Resident #35, the medical record showed an admission with diagnoses including sepsis, absence of the left foot, and diabetes mellitus type two. The care plan dated before a care conference indicated a discharge home, while the conference confirmed a long-term care status. The Regional MDS Nurse verified that only one care plan conference was documented, and the care plan was not updated to reflect the resident's long-term care status. The facility's policy required regular interdisciplinary team meetings to review care plans, which were not adhered to in these cases.
Failure to Provide Oral Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary oral care for a resident who had hemiplegia and hemiparesis affecting the right dominant side and required supervision or touching assistance for oral hygiene. The resident, who was cognitively intact, had a physician's order for oral care every shift and was admitted with diagnoses including cerebral infarction and ulcerative colitis. Despite these requirements, observations on multiple occasions revealed a buildup of food and plaque on the resident's teeth, indicating a lack of oral hygiene care since admission. Interviews with the resident and her mother confirmed that no oral care had been provided since the resident's admission, and there were no supplies for oral care in the resident's room. The Director of Nursing was informed of the situation and acknowledged the lack of oral care supplies. The facility's policy stated that residents would receive personal care according to their plan of care, which includes oral care, but this was not adhered to in the case of this resident.
Deficiency in Weight Monitoring and Reweighing Procedures
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring for residents, which is crucial for maintaining their nutritional health. Resident #15, who was admitted with diagnoses including PTSD, bipolar disorder, and hypertension, had inconsistent weight records. His weight was recorded as 160.2 pounds on admission, 158.2 pounds in August, and an inaccurate 1722.0 pounds in October, with no weight recorded for September. Interviews revealed that the dietician oversight was inconsistent during this period, and the staff failed to reweigh Resident #15 to confirm his actual weight. Resident #31, diagnosed with obstructive pulmonary disease, acute respiratory failure, and other conditions, also experienced issues with weight monitoring. His weight was recorded as 221 pounds on admission, 218 pounds in June, 222 pounds in August, and an inaccurate 146.8 pounds in October, indicating a significant weight loss. However, there were no weights recorded for July and September, and the staff did not reweigh him to verify the October weight. The facility's policy required monthly weights and reweighs for significant variances, which were not followed. Resident #195, with diagnoses including chronic bronchitis and heart failure, had fluctuating weights due to edema. Her weight was recorded as 174.5 pounds on October 2, 201.6 pounds on October 3, and 187.0 pounds on October 8, with no reweighs noted. The facility's policy required weekly weights for new admissions and reweighs for significant variances, which were not adhered to. The lack of accurate weight monitoring and reweighs for these residents indicates a deficiency in the facility's adherence to its weight policy and procedures.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent trauma-informed care for a resident diagnosed with PTSD, bipolar disorder, major depression with severe psychotic symptoms, and hypertension. The resident, a Vietnam War veteran, had identified trauma triggers but did not have a care plan addressing these triggers or interventions to manage them. The resident's medical records and assessments indicated a history of psychiatric hospital stays and behaviors such as verbal outbursts, rejection of care, and wandering, yet no specific care plan was in place to address these issues. Interviews with facility staff, including the Director of Nursing and a State Tested Nursing Assistant, revealed a lack of awareness and training regarding the resident's PTSD and potential triggers. The Director of Nursing confirmed the absence of a care plan for the resident's PTSD and acknowledged that staff had not been educated on managing the resident's condition. The facility's policy on trauma-informed care required staff education and care planning for identified triggers, but this was not implemented for the resident. Observations of the resident's behavior, such as pacing and verbal aggression towards other residents, further highlighted the deficiency in care. The facility's failure to document and educate staff on the resident's PTSD and triggers resulted in inadequate management of the resident's condition, contrary to the facility's policy on trauma-informed care.
Failure to Conduct AIMS Test and Monitor Depakote Levels
Penalty
Summary
The facility failed to ensure that an Abnormal Involuntary Movement Scale (AIMS) test was completed for a resident who was prescribed Olanzapine, an antipsychotic medication. The resident, who had diagnoses including PTSD, bipolar disorder, and major depression with severe psychotic symptoms, was admitted on 07/30/24 and had been receiving Olanzapine since admission. Despite the facility's policy requiring AIMS testing upon initiation of psychotropic medications and at least every six months, no AIMS test was conducted for this resident. The Director of Nursing confirmed the absence of the AIMS test, which is crucial for monitoring potential adverse side effects of the medication. Additionally, the facility did not ensure appropriate diagnosis and lab monitoring for another resident's use of Depakote, a medication prescribed for behavioral issues. This resident, diagnosed with dementia and other cognitive disturbances, had been receiving Depakote without any orders for monitoring Depakote levels through lab tests. The care plan did not include monitoring for Depakote, and the last psychiatric note was dated over a year prior, with no subsequent follow-up. The Director of Nursing confirmed that no Depakote levels had been drawn, indicating a lack of proper monitoring as required by the facility's policy on unnecessary drugs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 577 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boardman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shepherd Of The Valley-boardman | 0.2 mi | ★★★★★ | 21 | 0 |
| Beeghly Oaks Center For Rehabilitation & Healing | 1.3 mi | ★★★★★ | 0 | 0 |
| Briarfield Place | 2.3 mi | ★★★★★ | 3 | 0 |
| Shepherd Of The Valley Poland | 2.7 mi | ★★★★★ | 9 | 0 |
| Oasis Center For Rehabilitation And Healing | 2.8 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.