Valley View Health: Wound Care Notification Failures - OH
The 58-bed facility violated federal notification requirements when staff discovered two wounds on the resident's buttocks but treated them without physician orders, according to an August inspection report.
Resident #1 entered Valley View on June 2 with severe memory impairment, aphasia, and an existing pressure ulcer on her tailbone. She was incontinent and required substantial assistance with personal care.
Her admission skin assessment on June 3 showed no problems with her buttocks or tailbone area. But that changed six weeks later.
At 2:51 a.m. on July 8, a certified nursing assistant documented finding an open area on the resident's buttock. The next morning at 4:36 a.m., Registered Nurse #232 discovered two new wounds on the woman's buttocks.
The left wound measured four centimeters by three centimeters. The right wound measured two centimeters by one centimeter.
RN #232 immediately began treatment. She placed Xeroform dressing on the larger wound and Durafiber on the smaller one. Her notes indicated nursing staff would monitor the wounds and a wound care clinician would assess them.
But the nurse never called the resident's doctor. She never contacted the family.
The facility had no physician orders for the dressings RN #232 applied. Federal rules require nursing homes to immediately notify doctors and families when residents develop new conditions requiring treatment changes.
Valley View's own policy, last reviewed in December 2024, states physicians should be notified when there's a need to alter treatment due to health deterioration.
Two days passed before anyone sought medical orders. On July 11 at 9:21 p.m., a physician finally ordered wound care: cleanse with wound cleanser or saline, pat dry, apply triad to the wound bed, and cover with dry dressing daily.
LPN #233 confirmed to inspectors on August 19 that no one had notified the physician or family about the wounds. The nurse acknowledged she hadn't contacted the doctor for wound care orders and verified no orders existed until July 11.
By July 15, the resident's care plan was updated to reflect a pressure ulcer on her tailbone area.
The resident had multiple risk factors for skin breakdown. Her care plan from June 12 noted she was at risk due to mobility limitations, communication and cognitive deficits, and incontinence.
Pressure ulcers develop when sustained pressure cuts off blood flow to skin and underlying tissue. They're among the most serious complications nursing home residents face, often indicating inadequate care.
The delay in notification meant the resident's doctor couldn't immediately assess the wounds or adjust her treatment plan. Family members remained unaware their loved one had developed new medical problems requiring ongoing care.
Valley View's failure affected one of three residents inspectors reviewed for notification compliance during their August 22 complaint investigation.
The facility must now correct its notification procedures to ensure doctors and families learn immediately when residents develop new conditions requiring treatment changes.
For the resident with severe memory impairment who couldn't advocate for herself, those two days of unauthorized treatment and delayed communication represented a breakdown in the basic protections nursing home regulations are designed to provide.
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.
Resident #1 entered Valley View on June 2 with severe memory impairment, aphasia, and an existing pressure ulcer on her tailbone.
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.