Health inspection·January 24, 2025

F 0584 28 Pa. Code 207.2(a) Administrator's Responsibility. 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: 395563 If continuation sheet Page 2 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and/or the resident's responsible party regarding the reason for transfer to the hospital for five of 33 residents reviewed (Residents 1, 29, 35, 54, 59). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 30, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others. A nursing note for Resident 1, dated July 18, 2024, at 2:30 p.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital. A nursing note for Resident 1, dated November 20, 2024, at 9:23 a.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital. A nursing note for Resident 1, dated November 23, 2024, at 6:23 a.m., revealed that Resident 1 was admitted with congestive heart failure (CHF). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS assessment for Resident 29 revealed that the resident was sometimes understood and could sometimes understand others. A nursing note for Resident 29, dated January 14, 2025, at 4:56 p.m., revealed that the writer was called to the resident's room at 4:46 p.m. due to a fall. The resident was lying on the floor face down parallel to his bed. The resident was yelling get me up! The resident had a small skin tear present on his left second finger; however, the resident did yell out in pain while leaning him forward. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate. A nursing note for Resident 29, dated January 15, 2025, at 3:07 p.m., revealed that the resident was going to be admitted to the hospital for 24-hour observation with diagnosis of altered mental status. There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. An admission MDS for Resident 35, dated May 8, 2024, revealed that the resident was sometimes understood and could sometimes understand others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 3 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A nursing note for Resident 35, dated July 31, 2024, at 8:06 a.m., revealed that the resident was resting in bed with his eyes closed. The resident was not easily arousable to verbal stimuli and staff had to use physical stimuli to awaken the resident. The resident was not verbal that a.m. and slightly confused, and was only oriented to self. The resident's right pupil was sluggish during the assessment. A nursing note at 9:12 a.m. revealed that the physician was aware, and orders were received to send the resident for a CT scan. A nursing note at 9:50 a.m. revealed that the resident was sent to the hospital for further evaluation. A nursing note at 2:25 p.m. revealed that the resident will be admitted for acute head injury with bleeding. There was no documented evidence that a written notice of Resident 35's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. Interview with the Director of Nursing on January 23, 2025, at 1:40 p.m. confirmed that there was no documented evidence that a written notice of Resident 29 and Resident 35's transfers to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the residents and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS for Resident 54, dated September 24, 2024, revealed that the resident was usually understood, could usually understand others, and was severly cognitively impaired. A quarterly MDS for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood and could sometimes understand others. A nursing note for Resident 54, dated December 6, 2024, at 7:57 p.m., revealed that the writer was called to the nursing desk due to a fall. The resident was witnessed to have fallen on his face from the wheelchair. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate. A nursing note for Resident 54, dated December 25, 2024, at 3:57 p.m. revealed that the writer was called to the the resident's room due to a change in condition. The resident was not acting right and was leaning to the right side. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluated. There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. A quarterly MDS assessment for Resident 59, dated December 26, 2024, revealed that the resident was moderately cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, and had diagnoses that included diabetes and heart disease. A nursing note for Resident 59, dated April 16, 2024, at 12:50 p.m., revealed that the resident had a fall and complained of pain in her forehead, knee, and left arm. The physician was notified, and the resident was sent to the hospital for an evaluation and was admitted . There was no documented evidence that a written notice of Resident 59's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 4 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0623 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital and/or the reason for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 5 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 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. Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for one of 33 residents reviewed (Resident 59). Findings include: A nursing note for Resident 59, dated March 16, 2024, indicated that the resident was transferred to the hospital and was being admitted after a change in condition. There was no documented evidence that the resident and/or the resident's representative were provided with written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of the transfer to the hospital. Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that there was no documented evidence that a written notice of the facility's bed hold policy was provided to Resident 59 and/or the resident's representative at the time of the resident's transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 6 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of policies, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in resident care needs for four of 33 residents reviewed (Residents 8, 26, 53, 66). Findings include: The facility's policy regarding care plans, dated November 7, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia. A nursing note for Resident 8, dated June 21, 2024, revealed that the nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had used Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, use toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine. Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove creams kept at the bedside. As of January 22, 2025, there was no documented evidence that Resident 8's care plan was revised/updated to include that bedside creams should be removed. Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items. Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's care plan was not revised/updated to include that bedside creams should be removed. An admission MDS assessment for Resident 26, dated December 9, 2024, indicated that the resident was cognitively impaired, and that she was medicated with an anticoagulant (blood thinner). Physician's orders for Resident 26, dated December 3, 2024, included an order for the resident to receive 20 milligrams (mg) of Xarelto (blood thinner) daily until January 1, 2025, at which time the medication would be discontinued. Resident 26's care plan, dated December 9, 2024, revealed that the resident was medicated with a blood thinner. There was no documented evidence that Resident 26's care plan was updated to reflect the discontinuation of the blood thinner. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 7 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with the Director of Nursing on January 24, 2025, at 9:13 a.m. confirmed that Resident 26's care plan was not updated after the discontinuation of the blood thinner and it should have been. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, indicated that the resident was severely cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had a catheter related to the diagnosis of neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged resulting in difficulty urinating or incontinence). Clinical notes for Resident 53, dated June 3, 2024, indicated that while performing a.m. care the aide noted a tear of the penis meatus (opening for urine) with scant bleeding. A physician's order for Resident 53, dated June 4, 2024, included an order to cleanse the penis with soap and water, pat dry and apply bacitracin every shift for skin tear to the meatus (opening for urine). A current care plan indicated treatment to the residents skin tear was ongoing; however, physician orders indicated that the treatments were discontinued on November 6, 2024. Interview with the Director of Nursing on January 22, 2024, at 9:51 a.m. confirmed that Resident 53's care plan should have been updated to reflect that the treatments to the resident's penis were discontinued, and it was not. A quarterly MDS assessment for Resident 66, dated September 13, 2024, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had heart failure and hypertension (high blood pressure). A care plan dated July 5, 2024, revealed that Resident 66 was at risk for falls due to deconditioning, gait and balance problems, weakness and non-compliance with transfers and ambulation. A fall investigation for Resident 66, dated October 30, 2024, revealed that the resident had a fall from a high bed. The immediate intervention was to remove the bed remote out of reach from the resident. There was no documented evidence to indicate that the fall care plan was updated to reflect that the bed remote should be kept out of his reach. Interview with the Director of Nursing on January 22, 2025, at 9:51 a.m. confirmed that Resident 66's care plan should have been updated to reflect that the bed remote control should not be in reach, and it was not. 28 Pa. Code 211.12(d)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 8 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 - 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. Based on review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 8). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia. A care plan, dated June 14, 2024, revealed that the resident was at risk for falls related to gait/balance problems, as well as a history of non-compliance with transfers and ambulation. The resident was an assist of one staff with a gait belt and a wheeled walker for her transfers. Nursing notes for Resident 8, dated June 15, 16, and 17, 2025, revealed that the resident had been observed self-ambulating and that despite much education to the resident by staff on the importance of ringing her call bell and waiting for staff assistance, the resident's non-compliance with self-transfers continues. A nursing note for Resident 8, dated June 26, 2024, revealed that the writer was called to the resident's room due to a fall. The resident had tried to self-ambulate to the bathroom and fell inside of the bathroom. There was no documented evidence that any new interventions to prevent the resident from self-transferring without staff assistance were initiated prior to Resident 8's fall on June 26, 2024. Interview with the Nursing Home Administrator and the Director of Rehabilitation on January 22, 2025, at 1:12 p.m. revealed that Resident 8 was on therapy case load for strengthening and balance training in attempts to get the resident back to being independent at that time. On June 11, 2024, the resident's transfer status was changed from being independent to being a one assist. The Nursing Home Administrator confirmed that the resident was educated by staff when they observed the resident self-transferring; however, there were no new and/or revised interventions to prevent the resident from self-transferring without staff assistance initiated prior to Resident 8's fall on June 26, 2024. A nursing note for Resident 8, dated June 21, 2024, revealed that a nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had taken Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) and was using it on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, used toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine. Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove bedside creams. As of January 22, 2025, there was no documented evidence that Resident 8's care plan was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 9 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 revised/updated to include that bedside creams should be removed. Level of Harm - Minimal harm or potential for actual harm Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items. Residents Affected - Few Interview with Nurse Aide 2 on January 22, 2025, at 2:44 p.m. confirmed that there were two tubes of Calmoseptine in Resident 8's plastic bin in her bathroom. She indicated that this morning the resident rang her call bell and when she responded to the call bell, she found that the resident had self-transferred to the bathroom. Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's Calmoseptine should not have been in the resident's room. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 10 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for the care and maintenance of intravenous catheters, failed to ensure that intravenous catheters were flushed according to facility policy, and failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for one of 33 residents reviewed (Resident 29). Residents Affected - Few Findings include: The facility's policy regarding flushing peripheral catheter (a thin, flexible tube that is inserted into a vein to administer fluids, blood, or medications), dated November 7, 2024, indicated that peripheral intravenous (IV) catheters will be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications. Staff was to use the push-pause technique to instill the normal saline. Physician's orders for Resident 29, dated November 15, 2024, included an order for the resident to receive one gram (gm) of Meropenem (used to treat infections caused by bacteria) intravenously every six hours for a urinary tract infection for seven days. Physician's orders for Resident 29, dated November 15, 2024, and discontinued on November 24, 2024, included an order for the resident to receive a 10 milliliter (ml) normal saline flush every shift for IV maintenance until the completion of his antibiotic. Resident 29's Medication Administration Records (MAR's) for November 2024 revealed that there was no document evidence that staff administered the 10 ml normal saline flush during the dayshift on November 24, 2024, or during the evening shift on November 15, and 22, 2024. Resident 29's MAR's for November 2024 revealed that staff administered the IV Meropenem on November 15, 2024, at 8:00 p.m.; on November 16 through 21, 2024, at 2:00 a.m., 8:00 a.m., 2:00 p.m. and 8:00 p.m.; and on November 22, 2024, at 2:00 a.m., 8:00 a.m., and 2:00 p.m However, there was no documented evidence that staff flushed the resident's IV catheter with normal sterile saline solution before and after the administration of the Meropenem. A nursing note for Resident 29, dated November 27, 2024, revealed that the resident's IV catheter was removed at this time. However, there was no documented evidence that Resident 29's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed. Interview with the Director of Nursing on January 23, 2025, at 3:05 p.m. confirmed that there was no documented evidence that Resident 29's IV catheter was flushed with the 10 ml of normal saline during the dayshift on November 24, 2024, and during the evening shift on November 15, and 22, 2024; that there was no documented evidence that the resident's IV catheter was flushed with normal sterile saline solution before and after the administration of the Meropenem; and that there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 11 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 33 residents reviewed (Resident 62). Residents Affected - Few Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated December 5, 2024, revealed that the resident was cognitively intact and had diagnoses which included PTSD. A care plan for the resident, dated September 11, 2024, revealed that the resident had a potential for mood problems related to his PTSD. An interview with Resident 62 on January 22, 2025, at 10:38 a.m. revealed that he was a war veteran and that he had a terrible motor vehicle accident. He stated that he had some trauma from both of those life events. However, there was no documented evidence that the facility completed an assessment for a history of trauma for Resident 62 to identify specific triggers that could re-traumatize the resident. Interview with the Nursing Home Administrator on January 22, 2025, at 2:09 p.m. confirmed that there was no documented evidence of an assessment for a history of trauma being completed for Resident 62. 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 12 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 54). Findings include: The facility's policy for controlled substances, dated November 7, 2024, revealed that facility staff should document the time and day of administration, amount administered, and remaining quantity. Each dose of a medication shall be initialed on the Medication Administration Record (MAR) after the medication was actually administered. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood, and could sometimes understand others, required assistance with all care needs, and had diagnosis that included depression. Physician's orders for Resident 54, dated December 4, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a narcotic anxiety medication) every six hours as needed for restlessness for 14 days. Physician's orders for Resident 54, dated December 28, 2024, included an order for the resident to receive 0.5 mg of Ativan every six hours as needed for restlessness and anxiety for 30 days. Review of the December 2024 and January 2025 controlled drug records for Resident 54 revealed that 0.5 mg of Ativan was signed out on December 9, 2024, at 4:30 a.m.; December 11, 2024, at 11:00 p.m.,; and January 11, 2025, at 10:00 p.m. However, there was no documented evidence in Resident 54's clinical record, including the MAR, that the signed-out dose of the controlled medication was administered to the resident on the above-mentioned date and time. Interview with the Director of Nursing on January 24, 2025, at 12:15 p.m. confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of controlled medications mentioned above were administered to Resident 54. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 13 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending January 4, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 24, 2025, identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records. The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending January 4, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans. The facility's plan of correction for a deficiency regarding the pharmacy procedures, services, and records, cited during the survey ending January 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding pharmacy procedures, services, and records. Refer to F657 and F755. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 14 of 15 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 395563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrisons Cove Home 429 South Market Street Martinsburg, PA 16662 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 Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed during wound care for one of 33 residents reviewed (Resident 53). Residents Affected - Few Findings include: The facility's policy regarding wound care and hand washing/hand hygiene, dated November 7, 2024, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, revealed that the resident was severely cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, received hospice, had diagnoses that included multiple sclerosis and sacral wounds, and had a Stage 4 pressure ulcer (skin breakdown from pressure that exposes fat under the skin). Physician's orders, dated October 29, 2024, included an order to wash around the wound bed with water and antibacterial soap, pat dry, cleanse wound with a four by four (gauze sized four inches by four inches) soaked in 0.25 percent acetic acid solution, apply A and D ointment (a thick skin protective) to the peri wound, loosely pack wound bed and undermining with Aquacel Ag (a type of wound dressing that contains ionic silver), and cover with an abdominal pad and secure. Observations of Resident 53's wound care on January 23, 2025, at 11:15 a.m. revealed that Licensed Practical Nurse 3 washed her hands and put on a gown and gloves prior to placing a barrier on the bed and cleaning around the wound on the resident's sacrum with water and antibacterial soap. She then patted the area dry, cleaned the sacral wound with 0.25 percent acetic acid solution, patted dry, disposed of the barrier, removed her gloves, washed and dried her hands and donned new gloves, applied A and D ointment on the periphery of the wound, applied Aquacel Ag using a large Q-tip to press the dressing into the wound, and covered the wound with an abdominal pad and secured with tape. Licensed Practical Nurse 3 then touched the resident's skin below the dressing area, adjusted the resident's pillow and protective heal boots, and then used the bed controls to reposition the bed. Licensed Practical Nurse 3 then gathered the supplies, placed items into the garbage, removed her gloves, and washed her hands. Licensed Practical Nurse 3 did not remove her gloves and wash her hands after providing wound care and before adjusting Resident 53's pillow, protective heel boots, and bed controls. Interview with Licensed Practical Nurse 3 on January 23, 2025, at 11:36 a.m. confirmed that she did not remove her gloves and wash her hands after Resident 53's wound care and prior to providing care to the resident. Interview with the Director of Nursing on January 23, 2025, at 1:35 p.m. confirmed that Licensed Practical Nurse 3 should have removed her gloves and washed her hands prior to adjusting the pillow, protective heel boots, and bed controls, as that was considered moving from a dirty to a clean task. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395563 If continuation sheet Page 15 of 15