Inspection·March 21, 2024

F 0689 of the resident experiencing, expressing, or exhibiting signs or symptoms of pain, aside from that the resident was prescribed Tylenol for pain. Level of Harm - Actual harm Residents Affected - Few Review of a nursing progress note dated 03/05/24 and timed 5:58 P.M. revealed Resident #11 had a fall while being transferred to a shower chair. Resident #11's left leg was in a compromised position, the resident appeared to be in pain, and emergency medical services were called. Review of an interdisciplinary team progress note dated 03/07/23 and timed 9:02 A.M. revealed Resident #11 sustained a fall while transferring from the bed to a shower chair. The resident was sent to the hospital and a lift evaluation was to be completed upon the resident's return. Review of the hospital records dated 03/05/24 through 03/09/24 revealed Resident #11 sustained a fall and was having severe bilateral knee pain. The resident was taken from her nursing home to the local hospital to be evaluated and was found to have bilateral distal femur fractures. The resident was transferred to another hospital where she received orthopedic surgery for a left distal femur fracture and a right supracondylar distal femur fracture. Review of the staff witness statement, dated 03/05/24, revealed State Tested Nurse Aide (STNA) #304 was going to assist Resident #11 with a shower and needed assistance transferring the resident from the bed to a shower chair. STNA #304 asked STNA #307 to help. STNA #304 and STNA #307 were assisting Resident #11 when Resident #11's legs gave out and the resident started to drop to her knees and was lowered to the floor. Resident #11 sat on her buttocks with her legs out to the side and was leaning against STNA #304's legs while STNA #307 went to get the nurse. Review of the staff witness statement, dated 03/05/24, revealed STNA #304 came to get STNA #307 and said she needed assistance transferring a resident (#11). STNA #304 and STNA #307 attempted to transfer Resident #11 as a two-person assist from the bed to a shower chair. The resident's legs buckled, and the resident went down on her knees. The resident stated, Get me up. The bed was lowered and both STNA #304 and STNA #307 attempted to get the resident up as a two-person assist without success. The resident was lowered to her buttocks with her legs to the side. The resident leaned against STNA #304's legs while STNA #307 went to get the nurse. Review of the nursing progress note dated 03/09/24 and timed 5:50 P.M. revealed Resident #11 returned from the hospital. Review of the nursing progress notes dated 03/10/24 and timed 12:49 A.M. revealed Resident #11's skin assessment was completed. The resident had a total of seven incisions. The right lateral thigh had two incisions, the upper incision with 35 staples, and the lower incision with 32 staples. The left lateral thigh had three incisions, the upper incision with 20 staples, the middle incision with 12 staples, and the lower incision with 25 staples. Resident #11's left knee also had three staples and her left inner thigh had 37 staples. Interview on 03/21/24 at 10:18 A.M. with STNA #321 revealed Resident #11 sustained a fall while being transferred. STNA #321 reported Resident #11 fell because two nurse aides were attempting to assist the resident as a two-person assist (under her arms) instead of using a stand-up lift as required. STNA #321 reported the resident ended up having to go out to the hospital and had two broken femurs. Interview on 03/21/24 at 3:32 P.M. with STNA #307 verified she was present when Resident #11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 2 of 4 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 03/21/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few sustained a fall on 03/05/24. STNA #307 verified she and STNA #304 attempted to transfer the resident via two-person assist (under her arms) and without a standing lift. STNA #307 reported when picking the resident up, the resident's knees buckled, and Resident #11 went on the ground. STNA #307 verified the staff should have been using a stand-up lift to transfer Resident #11 and reported she was not aware Resident #11 required the use of a stand-up lift at the time of the fall. Review of the facility policy titled, Fall Management Program, revised 05/31/17, revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The policy stated any orders received by the physician should be noted and carried out. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 03/06/24: • On 03/05/24, Resident #11 was immediately assessed after sustaining a fall and was sent to the hospital. • On 03/05/24, all nursing staff members were educated by the Administrator on verifying transfer statuses per resident profiles. Review of the education provided to nursing staff on 03/05/24 revealed staff must always follow the transfer listed on the resident profile. All staff education was confirmed as completed by 03/06/24. • On 03/05/24, an ad hoc Quality Assessment and Assurance (QAA) Committee meeting was held with the Administrator, the Director of Nursing (DON), Medical Director #195, and Regional Support Nurse #431. • On 03/05/24, all resident profiles were verified by Regional Support Nurse #431 to ensure transfer statuses were in place for all residents. • On 03/05/24, red dots were placed on resident name plates by Licensed Practical Nurse (LPN) #502 to indicate which residents required a mechanical lift for transfer. • On 03/05/24, all staff members were educated by the DON regarding red dots that were placed on the name plates and that they indicated mechanical lift. Resident profiles would need to be checked to verify which lift type. All staff education was completed by 03/06/24. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 3 of 4 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 03/21/2024 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 0689 Level of Harm - Actual harm On 03/05/24, LPN #502 initiated audits to check for red dots on resident name plates. There were no concerns identified. The audits continued three times per week for eight weeks, followed by two times per week for four weeks, and then as determined by the QAA Committee. Residents Affected - Few • On 03/05/24, LPN #502 initiated audits to check for employee knowledge of lift identifiers on name plates and care profiles. There were no concerns identified. The audits continued three times per week for four weeks, followed by once per week for eight weeks, and then as determined by the QAA Committee. • On 03/05/24, LPN #502 initiated audits to observe transfers were being completed per the resident care profiles. There were no concerns identified. The audits continued three times per week for eight weeks, followed by two times per week for four weeks, and then as determined by the QAA Committee. • Interview on 03/21/24 between 10:00 A.M. and 3:30 P.M. with STNA #312, STNA #321, Registered Nurse (RN) #199, and STNA #307 verified they were provided education regarding verifying resident transfer status prior to transfers and what red dots meant on resident name plates. All staff interviewed possessed appropriate knowledge of the education provided by the facility. This deficiency represents non-compliance investigated under Complaint Number OH00151761. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365841 If continuation sheet Page 4 of 4