Morrisons Cove Home

F-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

F-F755.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 395563 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395563 B. Wing 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 41233 potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was Residents Affected - Few 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).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 395563 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395563 B. Wing 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 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 395563