Mccormick Rehabilitation And Healthcare Center

F-F600, constituting substandard quality of care

Findings include:

Review of the facility's policy titled Abuse and Neglect revised March 2018 revealed, . abuse was defined as

the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse . and mental abuse .

1. Review of Resident R103's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment.

Review of Resident R83's annual MDS with an ARD of 03/03/25, revealed a BIMS score of 05 out of 15 which indicated severe cognitive impairment.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0600 Review of Resident R83's Nurse's Note, dated 03/09/25 at 9:55 AM, and located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN)3 revealed, . she heard someone yelling stop when nurse got to Level of Harm - Immediate the nursing station she observed [Resident R103] hitting [Resident R83] on her right arm several times, they were separated jeopardy to resident health or [Resident R103] was taken to her room and [Resident R83] was taken to A-side. Body audit performed. safety

During an interview on 05/01/25 at 9:48 AM, Licensed Practical Nurse (LPN)1 stated that on 03/09/25, she Residents Affected - Few was in the hallway and Resident R83 was sitting in her wheelchair in the hallway, when Resident R103 came around the nurse's station, and went into the parlor. She heard Resident R83 hollering, and when she ran back, she observed Resident R103 hitting Resident R83 on the arm and maybe on the chest with a closed fist. She immediately separated them and took Resident R103 to her room and left Resident R83 in hallway. A few minutes later she heard hollering again, and observed Resident R103 had returned and was hitting Resident R83 on her arms/chest again in the hall. At that time, she took Resident R103 back to her room for a second time and moved Resident R83 to the parlor by the nurse's station. Then a few minutes after that

she heard hollering again and returned for a third time and found Resident R103 hitting Resident R83 again in the parlor. She returned Resident R103 to her room and at that time she took Resident R83 to the other unit. LPN1 stated Resident R103 attacked Resident R83 three different times in about a 45-minute period. She said she told the Certified Nursing Assistant (CNA) staff to keep an eye on Resident R103. She said Resident R103 understood what she was doing. Whenever someone said something to her, she did not like, she immediately began hollering and cussing. Staff have tried to keep an eye on her whenever she came out of her room. They try and watch to see where she's going. But her behaviors went from 0 to 100 in seconds. There was usually any indication when she was about to escalate. LPN1 further stated staff were not doing enough to keep her or other residents safe. She did not know what staff could do to keep them safe. If they move her to another unit, she will just do the same thing there.

Review of facility documentation revealed that Resident R83 did not have a skin assessment completed at the time the incident occurred.

Review of Resident R103's EMR Psych Consult under the Assessments tab revealed two consults were completed on 03/10/25 and 04/15/25, and medications were adjusted. The Social Service Director (SSD) sent a referral for behavioral placement evaluation on 04/15/25, but there was no follow up after that date related to the status of the referral.

During interviews on 05/01/25 at 7:58 AM and 8:43 AM, both Certified Nursing Assistants (CNA) and CNA5, assigned to residents at the time the incident occurred, revealed they did not witness the incident and were unaware that Resident R103 required increased supervision.

During an interview on 05/01/25 at 3:41 PM, the Director of Nursing (DON) stated the facility substantiated

the abuse. However, he was unaware that Resident R103 was allowed to attack Resident R83 three separate times. The DON stated it was frustrating because that was not the information that staff reported to him. Based on what he stated staff told him it was not that serious. The DON thought Resident R103 hit Resident R83 once and they were separated and there were no further issues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0600 2. Review of Resident R6's EMR Progress Notes tab revealed a note authored by the Director of Nursing (DON) dated 04/14/25 at 3:39 PM that stated, [Resident R6] was outside being supervised during her smoke break. The opposing Level of Harm - Immediate resident [Resident R103] attempted to get past the residents who were near the door but became frustrated when she jeopardy to resident health or could not. She then pulled one resident's wheelchair backwards causing it to strike [Resident R6's] legs. [Resident R6] safety expressed her disdain towards the opposing resident's actions to which the opposing resident said, F**k you. As staff attempted to separate the two residents, the opposing resident slapped [Resident R6] on the knee and spit on Residents Affected - Few her smoking apron. Staff continued to separate the residents immediately, and no further incident occurred.

Review of facility provided incident investigation for the incident showed the initial report stated: Time of incident 04/14/25 at 3:00 PM [Resident R103] going outside to courtyard to smoke and she pushed a wheelchair which hit resident's legs. Resident became angry and both exchanged profanities - staff attempted to intervene but

before residents could be reached, [Resident R103] smacked resident on the leg and spit toward her. Both separated immediately and taken inside. Body audit showed no injuries.

During an interview on 05/01/25 at 10:20 AM, Resident R6 was in her wheelchair wearing a smoking apron and self-propelling on the path to the courtyard. Resident R6 remembered the incident and stated the wheelchair did not cause an injury, they exchanged some words she shouldn't have said, and Resident R103 started spitting on her apron then came closer and closer and hitting her knee. Resident R6 stated she went to grab her arm to stop her, but

the aide pulled her away before she could do so. Resident R6 stated her knee was a bit sore a few days.

During an interview on 05/01/25 at 3:17 PM, CNA2 stated, I was watching smoking and [male resident name] asked [Resident R103] to move him back. [Resident R103] moved [the] wheelchair towards [Resident R6] and [Resident R6] say I'm back here but [Resident R103] moved his wheelchair into her [Resident R6] stump. I tried to get up to move [the male resident] beside [Resident R6]. [Resident R103] started cursing [Resident R6] out, [Resident R6] told her 'because of you he hit me,' they went back and forth, I told them to chill out. [Resident R103] then spits on [Resident R6]. Finally [DON's name] came out and took [Resident R103] inside. He was out trying to calm [Resident R6] down, [Resident R103] came back out and swung around [DON] and hit [Resident R6] on the leg. So, he took her back in and she didn't come back out.

In a follow-up interview on 05/02/25 at 5:05 PM, the DON was advised of CNA2's interview. The DON denied [Resident R103] returned to the courtyard. I brought her in and went back out to [Resident R6], but [Resident R103] didn't come back out.

The surveyor asked how he found out about the incident, to come out, the DON replied [CNA2] reported it to me.

On 05/02/25 at 1:24 PM, the facility provided an acceptable removal plan, which included the following:

. Immediate Actions Taken:

1) Body audit complete for Residents 83 and Resident 6 and 103 to ensure no concerns.

2) Interview complete with Resident 83 and Resident 6 to ensure they feel safe and have no concerns with care or safety at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0600 3) Education initiated immediately with 100% of staff by DON/DSD/RDCS/designees on 5-1-25 to ensure understanding of reporting of abuse and resident to resident altercations and ensuring that residents are kept Level of Harm - Immediate separated and that all information and details are accurately reported to Administrative staff. jeopardy to resident health or safety 4) Interviews initiated with all residents by Admin staff and SS to ensure they have no concerns with abuse and that they feel safe at the facility. Residents Affected - Few 5) Education initiated with SS, DON, Operations Manager and Admin Nursing Staff by RDCS to ensure understanding of abuse and abuse reporting and ensuring that residents are kept separated and that all behaviors and interventions are care planned timely.

6) Rooms assignments were reviewed to determine whether or not proximity was an issue for resident 103 and resident 83, and for resident 103 and resident 6, with findings revealing that resident 103 resides on a separate hall than resident 83 and resident 6, therefore no room adjustments were deemed necessary.

7) Resident 103 was placed on 1:1 observation.

8) Resident 103 care plan was updated to reflect the 1:1 intervention.

9) Psychiatric services will continue to follow resident 103.

10) Compliance completion was confirmed as of 5-2-25 at 12:45 pm.

ADHOC QA Meeting Held 5-1-25

*Members Present were: [name] RN RDCS, [name] LNHA, [name] Operations Manager, [name] RN DON, [name] Dr via phone.

*Root Cause of issue is identified as lack of accurately reporting events and behaviors to Admin staff and failure to ensure residents kept separated once an alteration occurred and failure to follow up and accurately care plan interventions r/t behaviors and keeping residents separated.

*Education initiated for all staff by DON/RDCS to ensure understanding of abuse and abuse reporting and ensuring that residents are kept separated and free from abuse.

*Interviews initiated with residents with BIMs> 12 by SS and Admin staff to ensure they feel safe and have no concerns r/t abuse.

*Education initiated for all Admin Staff by RDCS to ensure understanding or reporting abuse, ensuring residents are kept safe and separated and that all interventions are care planned for residents regarding behaviors.

*All education will be provided to newly hired staff and agency staff prior to first shift worked.

*The above components have been implemented as of 5-1-25 by 7:30 pm, and 100% compliance was confirmed as of 5-2-25 at 12:45 pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0600 *The results of the interventions will be audited every shift times 4 four weeks and then every week times four weeks, and the results will be brought to the QAPI committee monthly for the duration of the Level of Harm - Immediate interventions. jeopardy to resident health or safety *The 1:1 interventions will continue indefinitely as deemed necessary per ongoing review of 1:1 observation documentation. Residents Affected - Few 40902

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 40902 potential for actual harm Based on record review, interview, and review of facility policy, the facility failed to ensure an injury of Residents Affected - Few unknown origin, and a fracture was thoroughly investigated for two of five residents (Resident (R)103 and Resident R83) reviewed for abuse out of 30 sample residents.

Findings include:

Review of the facility's policy titled Abuse and Neglect revised March 2018, revealed the staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes.

Review of Resident R103's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment.

Review of Resident R83's annual MDS with an ARD of 03/03/25, revealed a BIMS score of 5 out of 15, which indicated severe cognitive impairment.

Review of Resident R83's Nurse's Note dated 03/09/25 at 9:55 AM, and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN)3 revealed, . she heard someone yelling stop when nurse got to

the nursing station she observed the resident [Resident R103] hitting [Resident R83] on her right arm several times they were separated [Resident R103] was taken to her room and [Resident R83] was taken to A-side. Body audit performed. No skin tears, swelling, or discolorations noted at this time.

Review of the facility's investigative documentation revealed no evidence of Resident R83's skin assessment, no

interview with LPN1 who witnessed all three incidents or with Certified Nurse Aide (CNA)5 who was assigned to Resident R103 on 03/09/25, no interview with LPN3 who documented the incident in the EMR, and no other residents were interviewed.

During an interview with LPN1 on 05/01/25 at 9:48 AM, she stated that on 03/09/25 she was in the hallway and Resident R83 was sitting in her wheelchair in the hallway, when Resident R103 came around the nurse's station, and went into the parlor. She heard Resident R83 hollering, and when she ran back, she observed Resident R103 hitting Resident R83 on the arm and maybe on the chest with a closed fist. She immediately separated them and took Resident R103 to her room and left Resident R83 in hallway. A few minutes later she heard hollering again, and observed Resident R103 had returned and was hitting Resident R83 on her arms/chest again in the hall. At that time, she took Resident R103 back to her room for a second time and moved Resident R83 to the parlor by the nurse's station. Then a few minutes after that she heard hollering again and returned for a third time and found Resident R103 hitting Resident R83 again in the parlor. She returned Resident R103 to her room and at that time she took Resident R83 to the other unit. She said Resident R103 attacked Resident R83 three different times in about a 45-minute period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 425171 Department of Health & Human Services Printed: 08/27/2025 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 425171 B. Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

McCormick Post Acute 204 Holiday Road MC Cormick, SC 29835

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 0610 During an interview on 05/01/25 at 3:41 PM, the Director of Nursing (DON) stated that he and the Operations Manager conducted the facility's investigation. The DON stated after an abuse allegation a nurse would Level of Harm - Minimal harm or complete a body audit, talk to residents involved considering their BIMS, any witness and notify the sheriff's potential for actual harm office. The DON stated he interviewed LPN1, but he did not have any documentation or her statement. The DON agreed he should have interviewed other staff and obtained written statements from them, residents Residents Affected - Few statements and should have had documentation of Resident R83's skin assessment.

During an interview on 05/02/25 at 6:06 AM the Operations Manager, who was the Abuse Coordinator, stated there should have been more interviews conducted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 425171