Inspection·January 4, 2020

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #11's medical record revealed an admission date to the facility occurred on 04/18/18. Diagnoses which included dementia with psychosis and stroke. The record identified Resident #11 payer source was Medicaid. The record identified Resident #11 required hospitalization on 08/02/19 for a total of 12 days. The record lacked any evidence of bed hold notification at that time. Additionally, Resident #11 required hospitalization on 12/27/19. The record identified Resident #11's family was provided the bed hold notification, however the notification did not include the number of her remaining bed hold days for the year. Interview with Business Office Manager (BOM) #550 on 01/03/20 at 12:26 P.M. confirmed the bed hold notification dated 12/27/19 was not completed accurately and did not identify the number of remaining bed hold days and was not completed on 08/02/19. Review of the facility's policy titled Bed Hold Policy, last revised on 11/18/16, revealed the campus would properly inform the residents in advance of their option to make a bed-hold payment and the amount of the facilities bed hold charge. The policy further revealed the purpose of the policy was to follow all state and federal guidelines related to therapeutic bed hold. Based on record review, review of facility policy and staff interview, the facility failed to notify the resident's and/or resident representatives of the facilities bed hold policy when the resident discharged to the hospital. This affected two (#11 and #24) of two residents reviewed for hospitalization. The facility census was 58. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chorionic atrial fibrillation, heart failure and unspecified dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/01/19 revealed the resident had impaired cognition. The resident was noted to discharge to the hospital on [DATE] and returned from the hospital on [DATE]. There was no evidence in the resident's medical record the resident and/or resident's representative was provided the facility's bed hold policy at the time her discharge to the hospital on [DATE]. (continued on next page) 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 Page 1 of 3 Event ID: 365841 Printed: 05/15/2026 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 365841 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 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)