MC CORMICK, SC - Federal inspectors cited McCormick Post Acute for immediate jeopardy to resident health and safety after a resident with severe cognitive impairment physically attacked two other residents multiple times, with facility staff failing to provide adequate protection or supervision.
Repeated Physical Attacks on Vulnerable Residents
The most serious violations centered on a cognitively impaired resident, identified as R103, who carried out multiple physical assaults on fellow residents over several months. According to inspection records, R103 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment that significantly affected her ability to understand consequences or control impulses.
On March 9, 2025, R103 attacked another severely cognitively impaired resident (R83) three separate times within a 45-minute period. Licensed Practical Nurse 1 witnessed the incidents and reported that R103 "hit R83 on the arm and maybe on the chest with a closed fist." After the first attack, staff separated the residents, but R103 returned twice more to continue the assault.
"Her behaviors went from 0 to 100 in seconds. There was usually [no] indication when she was about to escalate," the witnessing nurse told inspectors, revealing the unpredictable nature of R103's aggressive episodes.
The attacks escalated again on April 14, 2025, when R103 assaulted a third resident (R6) during outdoor smoking supervision. The incident involved R103 pushing another resident's wheelchair into R6's legs, followed by verbal abuse, spitting, and physical striking. A nursing assistant reported that after staff attempted to intervene, R103 "swung around [the Director of Nursing] and hit [R6] on the leg."
Critical Breakdown in Safety Protocols
The inspection revealed fundamental failures in resident protection protocols. Multiple nursing assistants assigned to resident care during the March incident were unaware that R103 required increased supervision, demonstrating a breakdown in communication between nursing staff. Even more concerning, no skin assessment was completed for R83 immediately following the assault to document potential injuries.
The facility's Director of Nursing admitted he was initially unaware of the severity of the March incidents, stating he thought "R103 hit R83 once and they were separated and there were no further issues." This suggests critical information about the repeated nature of the attacks was not properly communicated up the chain of command.
Staff acknowledged they were "not doing enough to keep [residents] safe" but expressed uncertainty about effective intervention strategies. The witnessing nurse noted that simply moving R103 to another unit would likely result in similar incidents occurring elsewhere.
Medical Implications of Inadequate Protection
Physical assaults on nursing home residents, particularly those with cognitive impairments, pose serious medical risks beyond immediate injuries. Residents with severe cognitive impairment cannot adequately protect themselves or communicate distress effectively, making them extremely vulnerable to repeated victimization.
The lack of immediate skin assessments following physical altercations represents a critical gap in medical care. Prompt evaluation is essential to identify injuries that may not be immediately visible, particularly in elderly residents who may have fragile skin, compromised circulation, or conditions that affect wound healing. Without proper assessment, injuries can worsen and lead to complications such as infections or pressure wounds.
For residents with conditions like diabetes or malnutrition - common in nursing home populations - even minor injuries require careful monitoring as they may heal poorly or develop complications. The psychological trauma from repeated assaults can also manifest as increased agitation, sleep disturbances, or regression in cognitive or physical functioning.
Insufficient Investigation and Response Procedures
Inspectors found the facility's investigation of the abuse incidents was inadequate and failed to follow their own policies. The facility's abuse investigation lacked critical elements including interviews with key witnesses, proper documentation of victim statements, and comprehensive evidence gathering.
Despite having a detailed policy requiring thorough investigation of alleged abuse, facility administrators failed to interview the Licensed Practical Nurse who witnessed all three March attacks, the Certified Nursing Assistant assigned to R103, or the nurse who documented the incident. No written statements were obtained from witnesses, and resident statements were not properly documented.
The Operations Manager, who served as the Abuse Coordinator, acknowledged that "there should have been more interviews conducted." This admission highlighted the facility's failure to meet basic investigative standards required by federal regulations.
Systemic Issues with Care Assessments and Treatment
Beyond the abuse incidents, inspectors identified multiple failures in basic care protocols. A resident requiring weekly skin assessments due to high-risk conditions had not received documented evaluations despite having visible redness and irritation in multiple body areas. When nursing staff finally conducted an assessment, they discovered new concerning areas that had gone undetected.
The facility also inappropriately used restraints, with one resident having bed rails despite assessments indicating they were not needed or recommended. Federal guidelines require facilities to try alternative approaches before implementing physical restraints and to conduct thorough risk-benefit analyses with resident input.
Assessment failures extended to documentation requirements, with one resident going over 120 days without a required comprehensive evaluation being submitted for processing. Such gaps in assessment can lead to inadequate care planning and missed opportunities to address changing medical needs.
Dining and Nutrition Compliance Problems
Nutritional care violations affected resident health and preferences. The facility failed to follow planned menus, serving different foods than those listed and not preparing advertised alternate options. Kitchen staff acknowledged they "did not make the alternate food items listed on the menu" and could not modify the electronic ordering system to reflect actual meal preparation.
One resident with documented food intolerances repeatedly received foods she could not digest, despite clear preferences being listed in her care records. The facility's electronic system failed to properly coordinate dietary restrictions with meal preparation, resulting in residents receiving inappropriate foods that could affect their nutritional status and medical conditions.
Administrative and Communication Failures
The violations revealed broader systemic issues in facility management and communication. Staff reported that information about resident behavioral risks was not adequately communicated between shifts or departments. The lack of coordination between nursing, administration, and direct care staff created dangerous gaps in resident protection.
Documentation failures extended beyond individual care records to facility-wide systems. The absence of policies for critical processes like MDS assessment transmission and inadequate training on abuse reporting procedures demonstrated management oversight problems that affected resident safety and care quality.
Additional Issues Identified
Inspectors documented several other concerning practices including failure to maintain proper communication with external dialysis providers, inadequate explanation of binding arbitration agreements to cognitively intact residents who later had no memory of signing such documents, and insufficient coordination of hospice care assessments. These violations, while less severe than the immediate jeopardy findings, indicated broader patterns of inadequate attention to regulatory compliance and resident rights.
The facility provided an immediate removal plan including 24-hour observation for the aggressive resident, comprehensive staff education on abuse reporting, and enhanced administrative oversight. However, the scope and severity of the violations raised questions about the facility's overall commitment to resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mccormick Rehabilitation and Healthcare Center from 2025-05-02 including all violations, facility responses, and corrective action plans.
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