Inspection·March 9, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility's Standard Operating Procedure for Preserving Dignity with Indwelling Catheter, reviewed 12/31/22, revealed general guidelines to include keeping the drainage bag covered with an appropriate device. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 2 of 10 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 03/09/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interview, the facility failed to ensure physician orders and interventions were implemented to address a resident's lower extremity edema. This affected one (Resident #43) of one resident identified with bilateral lower extremity edema. The facility census was 54. Residents Affected - Few Findings include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cirrhosis, type II diabetes mellitus, edema, thrombophilia, and history of venous thrombosis and embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #43 had moderately impaired cognition and required the extensive assistance of one staff for the completion of dressing. Resident #43 had a history of edema. Review of the care plan last revised on 11/27/22 revealed Resident #43 was receiving a diuretic medication. Interventions included to observe cardiovascular system and fluid status to determine effectiveness of diuretic therapy (e.g., edema, jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds) and administer medications per physician orders. Review of Resident #43's physician orders dated 02/14/23 revealed an order for the the placement of Thrombo-Embolic Deterrent (TED) or anti-embolism hose on in the morning and remove at bedtime. Review of the vascular physician consultation dated 03/06/23 revealed Resident #43 was evaluated as a new patient for swelling of lower extremities. The physician indicated the swelling had been ongoing for at least a few months. Resident #43 spends most of his day sitting in a wheelchair with his feet dependent and minimally ambulatory. Recommend a venous insufficiency scan to see if there was some component of valvular insufficiency. The physician suspected at least part of the swelling was lack of mobility and spending long periods of time with his feet dependent. The plan included compression, elevation, and exercise. Observations on 03/06/23 at 8:11 A.M. revealed Resident #43 was seated in a wheelchair at the bedside with bilateral feet placed to the floor with a leg wrap to the left lower leg. No TED hose was in place to the right lower extremity and no elevation of the extremities was in place. On 03/07/23 at 9:49 A.M., Resident #43 was observed propelling himself in a wheelchair. Resident #43 was holding up the left leg with his right foot. Interview with Resident #43 at the time states he would like foot rests due to this process being tiring. There was no TED hose to the right lower extremity. At 12:10 P.M., Resident #43 was observed in the common area near the dining room propelling himself in the wheelchair holding up the left leg with his right foot. At 1:56 P.M., Resident #43 stated staff apply the TED hose sometimes and staff have not applied today (03/07/23). Resident #43's feet were placed on the floor and were not elevated. Observation and interview on 03/07/23 at 3:27 P.M. with Registered Nurse (RN) #392 confirmed Resident #43 did not have a TED hose applied to the right lower extremity and no encouragement was provided to elevate the lower extremities. RN #392 assessed the resident's lower extremities with two-plus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 3 of 10 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 03/09/2023 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 0684 edema noted. Level of Harm - Minimal harm or potential for actual harm Observation on 03/08/23 at 10:20 A.M. revealed Resident #43 was in the common area propelling himself in a wheelchair using arms and attempting to lift feet. No foot rests or elevation of the lower extremities was provided. At 12:00 P.M., Resident #43 was observed in his room seated in a wheelchair with his feet to the floor. No lower extremity elevation was provided. Residents Affected - Few Interview on 03/08/23 at 9:05 A.M. with RN #336 confirmed a plan of care was not established to address Resident #43's lower extremity edema with intervention including TED hose application, elevation of lower extremities or monitoring of edema. Interview on 03/09/23 at 7:45 A.M. with the Director of Health Services confirmed no specific interventions had been implemented to address Resident #43's lower extremity edema regarding elevation and consistent monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 4 of 10 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 03/09/2023 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident and staff interview, and review of manufacturer instructions for use, the facility failed to ensure pressure relieving intervention were implemented and operated as designed. This affected one (Resident #48) of three residents reviewed for skin breakdown prevention. The facility identified eight residents who received preventative skin care. The facility census was 54. Residents Affected - Few Findings include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, acute embolism and thrombosis left femoral vein, coronary artery disease, left leg above the knee amputation, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had mild cognitive impairment, required extensive assistance of one staff with activities of daily living including bed mobility, transfer, dressing, and hygiene. Resident #48 was at risk for pressure ulcer development with no skin breakdown. Review of the physician orders dated 06/17/22 revealed an order to encourage Resident #48 to float his heels while in bed and a pressure reducing mattress. Review of the nursing plan of care last revised on 02/28/23 revealed Resident #48 had a potential for alterations in skin integrity related to the need for assistance with mobility, incontinence, and diabetes mellitus. The goal included maintain intact skin. Interventions included the following: float heels as needed, pressure reducing mattress, and provide with pressure redistribution products for bed and chair as indicated. Observations were as follows: on 03/06/23 at 8:20 A.M., 03/07/23 at 6:40 A.M., 9:46 A.M., and 11:07 A.M. revealed Resident #48 was observed in bed positioned on his back and his heels were resting on the mattress without elevation. An overlay air mattress was in place appeared flat, deflated with a low pressure alarm light illuminated on the mattress air compressor. Observation and interview on 03/07/23 at 11:15 A.M. with State Tested Nurse Aide (STNA) #347 verified Resident #48's heels were not elevated and the air mattress was not inflating due to tubing (supply/return) broken. Resident #48 was additionally observed with slight redness to the coccyx and intact skin to the heel. Interview on 03/07/23 at 11:18 A.M. with Registered Nurse (RN) #397 verified she was unaware Resident #48's air mattress was not operating and confirmed there was no documentation in the medical record for nursing to ensure the air mattress was operational. Interview with Resident #48 on 03/07/23 at 12:15 P.M. revealed he was unable to indicate how long the mattress had not been inflating. He stated with the air mattress deflated, the bed surface was hard and uncomfortable. Review of the Air Mattress Manufacturer User and Service Manual dated 2013 revealed the low pressure alarm light illuminates if there is not enough pressure in the inner air cells. If this occurs, check the hose connection to the mattress to ensure the hoses are tightly connected without air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 5 of 10 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 03/09/2023 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 leakage. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 6 of 10 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 03/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, staff interview and policy review, the facility failed to ensure topical medications were stored in their original container until used. This affected two of two residents (#6 and #7) reviewed for medication storage. The facility census was 54. Findings include: Medical record review for Resident #6 revealed an admission date of 12/06/22. Resident #6 had a physician order dated 12/22/22 for biofreeze gel four percent topical to right shoulder for pain three times a day. Medical record review for Resident #7 revealed an admission date of 08/10/18. Resident #7 had a physician order dated 05/14/22 to apply medihoney gel 80% thin layer topical to opened area on left shin, cover with durafiber and wrap with kerlix daily Observation on 03/08/23 at 8:18 A.M. revealed there were two medications cups containing an unidentified gel like substances in the top drawer of the medication cart. Interview on 03/08/23 at 8:18 A.M. with Registered Nurse (RN) #396 revealed one medication cup contained biofreeze for Resident #6 and the other medication contained medihoney for Resident #7. RN #396 verified the medications were not stored in their original container until used. Review of the policy Medication Storage in the Facility, revised 10/2019, revealed all medication dispensed by the pharmacy are stored in the container with the pharmacy label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 7 of 10 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 03/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods in the walk-in freezer were properly sealed, labeled, and dated. This had the potential to affect all 54 residents identified by the facility as receiving food from the kitchen. The facility census was 54. Findings include: Interview and observations of the walk in freezer with Area Director of Food Service (ADFS) #306 on 03/06/23 at 7:17 A.M. in the walk in freezer revealed an open, unsealed, unlabeled bag of chicken breast; an open unsealed, unlabeled, and undated bag of chicken tenders; an open, unsealed, unlabeled, and undated bag of hot dogs covered in frost; an open, unsealed, unlabeled, and undated bag of hamburger patties; an open, unsealed, unlabeled, and undated pizza cookies; and an open, undated package of vegetable blend. ADFS #306 at the time of the observations verified the findings of multiple food items stored in the freezer which were unsealed, unlabeled, and/or undated. Review of the facility policy titled Food Labeling and Dating Policy, dated 01/2023, revealed any food products removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following: item name, date and time the food was labeled, use by date, initials of the person labeling the item and securely cover the food item. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 8 of 10 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 03/09/2023 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 policy review, the facility failed to ensure a shared glucometer was cleaned and disinfected after each use. This affected Resident #32 and had the potential to affect three other residents (#6, #310, and #311) on the 100 hall who utilized the same glucometer as Resident #32. The facility census was 54. Residents Affected - Some Findings include Medical record review revealed Resident #32 had an admission date of 01/13/23. Diagnoses included diabetes mellitus type two with diabetic nephropathy. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had mild cognitive impairment. Review of the physician orders dated 02/15/23 revealed Resident #32 received blood sugar monitoring before meals. Observation on 03/08/23 at 8:12 A.M. revealed Registered Nurse (RN) #396 carried the glucometer to Resident #32's room and placed it directly on the resident's bedside table without a barrier under the glucometer. RN #396 obtained Resident #32's blood sugar and administered medications. RN #396 carried the glucometer back to the medication cart and placed the glucometer directly on top of the medication cart. RN #396 then placed the glucometer in the top drawer of the medication cart and shut the drawer. At no time had RN #396 cleaned and disinfected the glucometer. Interview on 03/08/23 at 8:18 A.M. with RN #396 verified she had put away the glucometer without cleaning and disinfecting it. Review of the facility's list of residents who utilized the same glucometer revealed Resident #6, #310, and #311 utilized the same glucometer as Resident #32. Review of the facility policy titled Glucometer Cleaning and Control Test Guidelines, revised 12/01/21, revealed if glucometers were used from one resident to another, they should be cleaned and disinfected after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 9 of 10 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 03/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a resident's room was free of odors. This affected one (Resident #28) of one resident reviewed for environment. The facility census was 54. Findings include Medical record review revealed Resident #28 had an admission date of 07/16/20. Diagnoses included dementia, urethral stricture, obstructive and reflux uropathy, and history of malignant neoplasm of prostate. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mild cognitive impairment and had an indwelling catheter. Observation and interview of Resident #28's room on 03/06/23 at 10:28 A.M. revealed there was a strong urine odor in the resident's room. Resident #28 stated a few weeks ago, a staff member had not closed his urinary catheter bag correctly and it leaked all over. Subsequent observations on 03/07/23 at 10:18 A.M. and 2:47 P.M. and on 03/08/23 at 8:56 A.M. revealed the urine odor continued to remain present in the resident's room. Interview on 03/08/23 at 8:56 A.M. with Housekeeping Staff (HS) #328 verified there was a strong urine odor in Resident #28's room. HS #328 revealed the resident's carpet was cleaned about a month ago because his catheter bag had leaked. Review of the policy titled Room Cleaning-Health Center Rooms, revised 06/15/22, revealed resident rooms were cleaned daily and deep cleaned monthly. There were no guidelines for addressing room odors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 10 of 10