Health inspection·May 15, 2025

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 clinical record review and observation, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 1) Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia, diabetes, and end stage renal disease (kidney failure). Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 1 was cognitively impaired and required extensive assistance from staff for dressing. On April 30, 2025, the physician ordered for staff to apply geri sleeves (arm protectors) to both arms at all times except during hygiene. Multiple observations on May 15, 2025, between 10:00 a.m., and 12:40 p.m., revealed that Resident 1 was in bed without geri sleeves on his arms. CFR 483.25 Quality of Care Previously cited 3/6/25 28 Pa. Code 211.12(d)(1)(5) Nursing services. Page 1 of 2 395167 395167 05/15/2025 Valley Manor Rehabilitation and Healthcare Center 7650 Route 309 Coopersburg, PA 18036

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to implement safety interventions for two of eight sampled residents. (Residents 1 and 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia, diabetes, and end stage renal disease (kidney failure). The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 1 was cognitively impaired and required staff assistance for bed mobility and transfers. Review of the care plan revealed that the resident was at risk for falls and staff was to place mats on the floor on both sides of the bed while the resident was in bed. Review of facility documentation dated March 3, 2025, and April 5, 2025, revealed that the resident slid out of bed onto the floor. On March 9, 2025, documentation revealed that the resident was found on the floor at the foot of the bed. On April 2, 2025, documentation revealed that the resident was found lying with the top-half of his body against the bed frame. Multiple observations on May 15, 2025, between 10:00 a.m. and 12:40 p.m., revealed Resident 1 was in bed without mats on the floor on both sides of the bed. Clinical record review revealed Resident 2 had diagnoses that included kidney failure, heart failure, and convulsions (rapid involuntary muscle contractions). The MDS assessment dated [DATE], revealed Resident 2 was cognitively impaired and required staff assistance for bed mobility and transfers. Review of the care plan revealed that the resident was a risk for falls and staff was to place mats on the floor on both sides of the bed while the resident was in bed. On May 15, 2025, at 10:20 a.m., Resident 2 was observed in bed without mats on the floor on both sides of the bed. In an interview on May 15, 2025, at 1:25 p.m., the Administrator confirmed that mats should have been on the floor on both sides of the bed while Residents 1 and 2 were in bed. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395167 Page 2 of 2