Valley View Health Campus

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, staff interview, and facility policy review, the facility failed to timely notify the physician and responsible part regarding a new wound. This affected one resident (#1) of three residents reviewed for notification of change. The facility census was 58.Findings include:Review of Resident #1's medical record revealed an admission date of 06/02/25. Medical diagnoses included aphasia, anemia, weakness, constipation, a pressure ulcer of the sacral region that was unstageable, and a vitamin D deficiency.Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #1 had

a memory problem with severe impairment. Resident #1 was always incontinent of bowel and bladder, was dependent for toileting, and needed substantial assistance for showers and personal hygiene. Review of Resident #1's admission skin assessment completed on 06/03/25 revealed no identified skin impairments to the buttocks or coccyx upon admission. Review of Resident #1's care plan revealed on 06/12/25 Resident #1 was at risk for skin breakdown related to a need for assistance with mobility, communication and cognitive deficits, and incontinence. Further review of Resident #1's care plan revealed on 07/15/25 Resident #1 had a pressure ulcer on her coccyx. Review of Certified Resident Care Associate (CRCA) #524's documentation in Point of Care (POC) regarding skin problems on 07/08/25 at 2:51 A.M. revealed Resident #1 had an open area on her buttock. Review of Resident #1's progress notes signed by Registered Nurse (RN) #232 dated 07/09/25 at 4:36 A.M. revealed Resident #1 had two new wounds on her buttocks. The left wound measured four centimeters (cm) by three cm. The inner right wound measured two cm by one cm. RN #232 documented she placed Xeroform on the left wound and Durafiber on the right wound. RN #232 documented the nursing staff were to monitor and wound care clinician would assess.

There was no documentation the physician or family were notified. Review of Resident #1's physician orders revealed no order for the Xeroform or Durafiber dressing RN #232 placed on Resident #1. Review of Resident #1's physician orders revealed a new order was created on 07/11/25 at 9:21 P.M The order stated to cleanse the wound with wound cleanser or normal saline, pat dry, apply triad to the wound bed, and cover with dry dressing. This was to be changed daily. Interview with LPN #233 on 08/19/25 at 11:03 A.M. revealed the nurse had not provided notifications of the wound to the physician or family and had not contacted the physician for wound care orders. Furthermore, LPN #233 verified an order for a dressing was not in place until 07/11/25. Review of the facility policy titled Notification of Change in Condition with a last reviewed date of 12/17/24 revealed the physician should be notified when there is a need to alter the residents treatment such as a deterioration of health.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Health Campus

1247 North River Rd Fremont, OH 43420

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

two pressure ulcers from the photographs.

Level of Harm - Minimal harm or potential for actual harm

Interview on 08/19/25 at 3:04 P.M., LPN #233 after viewing photographs of the resident’s wounds stated she was confident the resident in the photograph was Resident #60. LPN #233 verified Resident #60’s orange shirt, bedside table and window blinds in the photograph. LPN #233 verified the wound dressing in one of the photographs had been dated 07/29/25 and recognized the staff nurse initials on the dressing. LPN #233 verified the wounds in the photographs were how the resident’s wounds had looked since her first assessment of the wounds on 07/15/25. LPN #233 stated for the wounds to be classified as a stage two pressure ulcer the wounds would have to be further down through the dermis.

LPN #233 reiterated the two wounds blanched and were not pressure ulcers.

Residents Affected - Few

Review of the facility policy “Guidelines for General Wound and Skin Care,” dated 05/10/17 revealed staff would know the indications and contradictions for the wound products used. Staff would document type of wound, location, stage (if applicable), length, width, depth in centimeters, base, drainage, peri wound tissue, and treatment of the wound weekly using the wound/skin treatment flow sheet. Staff would notify the wound nurse/nurse supervisor for all new stage two to four pressure ulcers or with any questions.

Review of the facility policy “Pressure Injury Staging Guide,” dated 2016, revealed a stage two pressure injury was partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, and moist. Adipose tissue would not be visible, and deeper tissues were not visible. Granulation tissue, slough, and eschar would not be present. This stage should not be used to describe MASD including incontinence associated dermatitis.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Valley View Health Campus

1247 North River Rd Fremont, OH 43420

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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

record review, observation, staff interview, and facility policy review, the facility failed to ensure proper infection control standards during incontinence care and a wound dressing change. This affected one resident (#1) of three residents reviewed for incontinence care and wound care. The facility census was 58.

Findings include:Review of Resident #1's medical record revealed an admission date of 06/02/25. Medical diagnoses included aphasia, anemia, weakness, constipation, a pressure ulcer of the sacral region that was unstageable, and a vitamin D deficiency.Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #1 had a memory problem with severe impairment. Resident #1 was always incontinent of bowel and bladder, was dependent for toileting, and needed substantial assistance for showers and personal hygiene. Review of Resident #1's admission skin assessment completed on 06/03/25 revealed no identified skin impairments to the buttocks or coccyx upon admission.

Review of Resident #1's care plan revealed on 06/12/25 Resident #1 was at risk for skin breakdown related to a need for assistance with mobility, communication and cognitive deficits, and incontinence. Further

review of Resident #1's care plan revealed on 07/15/25 Resident #1 had a pressure ulcer on her coccyx.

Observation on 08/18/25 at 3:30 P.M. of incontinence care and wound care for Resident #1 revealed LPN #233 rolled the patient to get the incontinence brief out from under the resident. When LPN #233 rolled the resident, LPN #233's gown was hanging loosely do to being untied around the back at the waist and her shirt was touching the resident. After removing the soiled brief, LPN #233 properly provided incontinence care and placed the soiled brief on Resident #1's bed. LPN #233 changed her gloves and completed hand hygiene between gloves. With the clean gloves, LPN #233 saturated gauze with Vashe wound cleansing solution and applied the gauze to Resident #1's wound per the physician orders. LPN #233 removed her gloves and discarded them. While waiting for the five minutes for the gauze to sit on the wound, Resident #1 appeared cold. LPN #233 moved the dirty brief with an ungloved hand from Resident #1's blanket and covered Resident #1 with the blanket. LPN #233 discarded the brief in a trash can. LPN #233 completed hand hygiene and applied clean gloves to complete the rest of the dressing change.Interview with LPN #233 on 08/18/25 at 3:51 P.M. verified she grabbed the soiled brief with an ungloved hand. Furthermore, LPN #233 verified she had not tied her gown and her shirt along with the untied gown touched Resident #1's body. Further interview with LPN #233 revealed she then placed the soiled wound dressing and soiled brief directly on the bedding. Review of the undated policy from the Centers for Disease Control (CDC) titled Sequence for Putting on Personal Protective Equipment revealed the gown should fully cover the torso from neck to knees, arms to the end of the wrist, and wrap around the back. The gown should be fastened in the back of the neck and the waist. Review of the facility policy with a reviewed date of 12/16/24 titled perineal care for incontinence revealed to pay particular attention to infection prevention and control techniques when performing pericare. Review of the facility policy Standard Precaution Guidelines, reviewed 12/17/24 revealed it is important for staff to use appropriate protective equipment as a barrier to exposure to any body fluids. Furthermore, the disposal of waste is also handled as though all body fluids are infectious. Potentially contaminated articles are stored and disposed of in appropriate containers.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet