Valley View Health Campus: Infection Control Failures - OH
The August 18 incident involved a resident with severe memory impairment who was always incontinent and needed substantial assistance with personal hygiene. The 58-bed facility had admitted the woman in early June with multiple conditions including aphasia, anemia, and weakness.
LPN #233 was providing care for a pressure ulcer that had developed on the resident's coccyx more than a month after admission. The woman had been assessed as having no skin problems on her buttocks when she arrived at the facility.
During the 3:30 p.m. care session, the nurse's protective gown hung loose and untied at the waist, allowing her shirt to touch the resident's body when she rolled the patient to remove the soiled brief. After properly cleaning the resident and changing gloves, the nurse placed the dirty brief directly on the bed.
The nurse then applied gauze saturated with wound cleansing solution to the pressure ulcer as ordered by the physician. She removed her gloves and discarded them while waiting the required five minutes for the treatment to work.
When the resident appeared cold, the nurse moved the contaminated brief from the blanket with her ungloved hand and covered the woman with the same blanket. She threw the brief in a trash can, washed her hands, and put on clean gloves to complete the dressing change.
The nurse acknowledged the violations when questioned by inspectors 21 minutes later. She confirmed grabbing the soiled brief with her bare hand and admitted her untied gown and shirt had touched the resident's body. She also acknowledged placing both the dirty brief and soiled wound dressing directly on the bedding.
Federal health regulations require protective gowns to fully cover healthcare workers from neck to knees and wrap around the back, with fastenings at both the neck and waist. The facility's own policies emphasize infection prevention during incontinence care and mandate that staff treat all body fluids as infectious.
Valley View's standard precaution guidelines, reviewed in December 2024, specifically require appropriate protective equipment as barriers to body fluid exposure. The policy states that potentially contaminated items must be stored and disposed of in appropriate containers.
The resident affected by the infection control failures had been identified as at risk for skin breakdown due to mobility limitations, cognitive deficits, and incontinence. Despite this assessment made 10 days after admission, she developed the pressure ulcer about five weeks later.
The facility's own perineal care policy instructs staff to pay particular attention to infection prevention techniques during incontinence care. Centers for Disease Control guidelines reviewed by inspectors specify that protective gowns should be properly fastened to prevent contamination.
The violations occurred during what should have been routine wound care for a vulnerable resident who depended on staff for basic hygiene needs. The nurse's actions created multiple opportunities for cross-contamination between the soiled brief, the open wound, and the resident's bedding.
Federal inspectors classified the infection control failures as having minimal harm or potential for actual harm. The facility serves 58 residents, and inspectors reviewed incontinence and wound care practices for three residents total.
The contamination incident highlights broader concerns about basic infection prevention in long-term care settings, where residents with cognitive impairments and mobility limitations rely entirely on staff to maintain sanitary conditions during intimate care procedures.
Valley View Health Campus had policies in place addressing proper protective equipment use and waste disposal, but staff failed to follow established protocols during the observed care session. The nurse's admission that she routinely placed soiled items on bedding suggests the violations may not have been isolated incidents.
The resident with the pressure ulcer remains dependent on staff for all aspects of personal care, including the ongoing wound treatment that was compromised by the infection control failures documented by federal inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Health Campus from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
VALLEY VIEW HEALTH CAMPUS in FREMONT, OH was cited for violations during a health inspection on August 22, 2025.
The August 18 incident involved a resident with severe memory impairment who was always incontinent and needed substantial assistance with personal hygiene.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.