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 21 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 21 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 21 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 21 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 21 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 21 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 21 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 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28154

Residents Affected - Few Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for processing for one of one residents triggered for no MDS in over 120 days, (Resident (R)31), out of a total sample of 30. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Findings include:

Review of Resident R31's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE REDACTED] and readmission on 06/24/24.

Review of Resident R31's Minimum Data Set (MDS) assessments from the EMR MDS tab showed the last transmitted and accepted assessment was a quarterly assessment on 12/26/24 and an annual MDS with an assessment reference date (ARD) of 04/23/25 and showed as export ready.

During an interview on 04/30/25 at 3:45 PM, regarding the four month gap in assessment transmissions, the MDS Coordinator (MDS)2 confirmed it was completed on 04/26/25 and was not yet transmitted, and it was over 120 days since the last transmission.

During an interview on 05/01/25 at 12:20 PM, MDS2 confirmed there is no facility policy regarding MDS transmission and the Resident Assessment Instrument (RAI) manual will be followed.

During an interview on 05/01/25 at 5:24 PM, regarding MDS timing, the General Manager stated the expectation is, that the MDS would be exported [clarified, completed & transmitted] per the RAI timeline.

Review of the October 2024 RAI Manual on page 2-34, revealed, The ARD of an assessment drives the due date of the next assessment. The next non- comprehensive assessment is due within 92 days after the ARD of the most recent OBRA [Omnibus Budget Reconciliation Act] assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment - + 92 calendar days).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 21 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 0637 Assess the resident when there is a significant change in condition

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40902 potential for actual harm Based on record review, interview and review of the Resident Assessment Instrument (RAI) manual, the Residents Affected - Few facility failed to complete a significant change assessment for a resident receiving hospice services for one of three residents, (Resident (R)112), reviewed for hospice.

Findings include:

Review of GUIDELINES FOR DETERMINING THE NEED FOR A SCSA FOR RESIDENTS WITH TERMINAL CONDITIONS from the RAI manual revealed, The key in determining if an SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of

the expected course of deterioration, an SCSA assessment is required. Similarly, if the resident enrolls in a hospice (Medicare Hospice program or other structured hospice program), but remains a resident at the facility, an SCSA should be performed if the terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration. The facility is responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Review of Resident R112's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed readmission to the facility on [DATE REDACTED].

Review of Resident R112's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 01/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognitive impairment. Further review revealed Resident R112 went on hospice on 03/19/25 but

a Significant Change in Status Assessment (SCSA) MDS was not completed.

Review of 112's Physician Orders located under the Orders tab of the EMR dated 03/19/25, revealed an order for hospice.

Review of Resident R112's Care Plan located under the ''Care Plan'' tab of the EMR and dated 04/07/25, revealed,

The resident was care planned for end of life/hospice services.

During an interview on 05/01/25 at 10:32 AM, the MDS1 and MDS2 stated when a resident was placed on hospice that information was communicated during their morning meetings. They also received a list of hospice residents from the Social Service Director (SSD). MDS1 and MDS2 stated that a SCSA should have been completed.

During an interview on 05/01/25 at 3:38 PM, the Director of Nursing (DON) stated that he expected after a resident was placed on hospice, that a SCSA MDS was completed accurately and timely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20243 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one Residents Affected - Few of two residents, (Resident (R)28), reviewed for skin conditions out of a sample of 30 residents received documented skin assessments identifying the status of the skin. In addition, the facility failed to ensure a resident was appropriately screened and had documentation to support the use of a wander guard for one of two residents, (Residents (R)106), reviewed for wander guards in the sample of 30 residents.

Findings include:

1. Review of the facility's policy titled, Skin assessment dated [DATE REDACTED] indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Monitoring included to evaluate, report and document potential changes in the skin.

Review of Resident R28's undated Admission Record found under the Profile tab of the electronic medical record (EMR) indicated that Resident R28 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: encephalopathy, anemia, peripheral vascular disease, hypertension, malnutrition, type 2 diabetes, cerebrovascular disease, and hemiplegia and hemiparesis affecting the right dominant side.

Review of Resident R28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, found under the MDS tab of the EMR indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident R28 was cognitively intact.

Review of Resident R28's Impaired Skin Integrity Care Plan with a review date of 03/20/25, found in the EMR under

the Care Plan tab indicated interventions of monitoring skin daily with routine care and weekly nursing assessments to observe for skin breakdown.

Review of Resident R28's Body Audit Schedule provided by the facility for the weeks of 04/07/25 - 04/13/25, 04/14/25 - 04/20/25, and 04/21/25 - 04/27/25, indicated that Resident R28 was scheduled weekly on Mondays for skin assessments.

During an observation of Resident R28's skin assessment on 04/30/25 at 1:45 PM, Licensed Practical Nurse (LPN)2 revealed redness under the right breast fold, dark redness on the perineum area, upper inner thighs, and the right and left buttocks to the waist. LPN2 stated that the redness under the right breast was new and that the nurse practitioner would be notified.

Review of Resident R28's EMR revealed no documentation pertaining to skin assessments of the perineum area, buttocks, abdominal folds, and breast folds.

During an interview on 04/30/25 at 5:30 PM, the Regional Director of Clinical Services (RDCS)1 stated that there was a schedule for weekly skin assessments at the nurses' stations; however, there was no documentation found for Resident R28's weekly skin audits. RDCS1 stated that there needed to be improvement in documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 21 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 0684 During an interview on 05/01/25 at 10:40 AM, the Nurse Practitioner (NP) stated that she had not received notification of Resident R28's reddened areas in the past week. The NP stated that she relied on the skin assessment Level of Harm - Minimal harm or documentation as part of her review of a resident's skin condition. potential for actual harm

During an interview on 05/02/25 at 7:34 AM, the Director of Nursing (DON) stated that he was not aware of Residents Affected - Few Resident R28's skin condition and that Resident R28's skin assessments were not being done. The DON's expectation going forward was to put a system in place that would help him track completion of skin assessments to ensure timely completion.

2. Review of Resident R106's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: paranoid schizophrenia.

Review of Resident R106's Quarterly MDS assessment under the MDS tab of the EMR, with an ARD of 02/03/25, revealed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Further review revealed no wandering behavior was exhibited.

Review of Resident R106's Care Plan located under the Care Plan tab of the EMR dated 02/10/25, revealed the resident was care planned for risk for elopement related to a responsible party reporting history of exit seeking. Interventions in place were personal security alarm.

Review of Resident R106's Nurses Notes located under the Notes tab of the EMR from admission on 01/28/25 until present revealed no documentation related to wandering or exit seeking behaviors.

Review of Resident R106's Physician Orders located under the Orders tab in the EMR dated 01/30/25, revealed secure care device.

Review of Resident R106's Elopement Risk Assessment located under the Observations tab in the EMR dated 01/28/25, revealed Resident R106 did not have any documented history of elopement attempts, and did not exhibit any unsafe wandering or elopement behaviors. The assessment indicated the family stated resident had a history or wandering and wanted to be at home.

During an interview on 04/30/25 at 11:42 AM, Resident R106 stated she did have a band on her ankle that she thought was her identity, but she said nobody has explained to her why she had to wear it. She stated that

she did not like to wear it because it irritated the skin on her leg.

During an interview on 05/01/25 at 8:04 AM, Certified Nurse Assistant (CNA)5 stated Resident R106 did not bother anyone and would walk down the halls but would respond to staff if they called her. She said she has walked by the doors, but she has never tried to open the door. There has never been any concern that she would try to leave.

During an interview on 05/01/25 at 8:23 AM, CNA4 stated that Resident R106 was independent and did not interact much. She usually just stayed in her room with the door shut but would let staff know when she needed anything. She was not aware of Resident R106 ever trying to leave or exit seek.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 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 0684 During an interview on 05/01/25 at 9:38 AM, Registered Nurse (RN)1 stated she completed Resident R106's elopement risk assessment on admission. She said sometimes the family expressed concerns for wandering Level of Harm - Minimal harm or or they would observe a resident wandering around the exit doors. She said the day of Resident R106 admission staff potential for actual harm had to redirect her constantly but agreed it was a new environment and that she has never personally seen her try to exit seek or try to open an exit door. She agreed it was not appropriate for Resident R106 to wear a wander Residents Affected - Few guard.

40902

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40902 potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure ongoing Residents Affected - Few communication and collaboration with the dialysis facility for one resident (Residents (R)108) reviewed for dialysis out of a sample of 30 residents. This had the potential to affect all residents receiving dialysis treatment.

Findings include:

Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with revised September 2010, revealed that Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how the care plan will be developed and implemented; how information will be exchanged between the facilities; and c. responsibility for waste handling, sterilization, and disinfection of equipment.

Review of Resident R108's Admission Record, found in the Profile tab of the electronic medical record (EMR) revealed

he was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: type two diabetes mellitus with diabetic chronic kidney disease.

Review of Resident R108's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 04/14/24 revealed Resident R108 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Further review revealed Resident R108 received hemodialysis.

Review of Resident R108's Care Plan located in the Care Plan tab of the EMR dated 04/08/25, documented that the resident needs dialysis related to renal failure. The interventions included for the resident to attend dialysis

on Tuesday, Thursday, and Saturdays.

Review of Resident R108's Treatment Details Report forms dated February 2025 thru April 2025 revealed the only documented form completed by dialysis and received by the facility for that time was on 04/11/25. There was no additional documentation from the dialysis center for that time.

During an interview on 04/30/25 at 3:45 PM, Licensed Practical Nurse (LPN)6 stated facility nursing staff completed a pre and post dialysis evaluation for the resident that was sent to the dialysis center, but the dialysis center was not great about sending it back. LPN6 stated she never reported when they did not get dialysis information.

During an interview on 05/01/25 at 3:20 PM, the Director of Nursing (DON) stated there was a dialysis worksheet that was sent to dialysis, but dialysis kept it and did not send it back. The DON stated that he expected their process to be followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40902 Residents Affected - Few Based on observation, interview, record review, and Food Drug Administration guidance, the facility failed to ensure a resident was appropriately evaluated for use of bedrail and that alternative measures were attempted prior to installation of side rails for one of one resident (Resident (R)27) reviewed for side rails out of a total sample of 22. The lack of alternate side rail measures had the potential to lead to safety concerns related to bed rail use.

Findings include:

Review of the Food and Drug Administration's Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003 and located at https://www.dfa.gov/media/88765, revealed, . Every patient, regardless of care setting, deserves a safe and comfortable sleeping and bed environment . Although various types may be used depending on a patient's medical and functional needs, bed rails may pose increased risk to patient safety . Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient . Decisions to use or to discontinue the use of a bed rail should be made in the context of an individualized patient assessment using an interdisciplinary team with input from the patient and family or the patient's legal guardian . Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment . Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient . Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan.

Review of Resident R27's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed

she was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: acute kidney failure.

Review of Resident R27's annual Minimum Data Set (MDS) located in the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 02/06/25, revealed Resident R27 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment.

Review of Resident R27's Care Plan dated 11/17/23, and located in the EMR under the Care Plan tab, revealed, The resident was at risk for Falls related to transferring self. Interventions in place were side rails as ordered.

During an observation on 04/30/25 at 11:46 AM, Resident R27 was in bed with quarter side rails on both sides of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 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 0700 Review of Resident R27's Bed Rail Evaluation, dated 11/06/24, 01/06/25 and 02/05/25, revealed Resident R27 did not use bedrails and bedrails were not indicated for use. Further review revealed no documentation of alternates Level of Harm - Minimal harm or used prior to bedrail use. potential for actual harm

Review of Resident R27's Physician Order, dated 01/06/25, and located in the EMR under the Orders tab revealed an Residents Affected - Few order for side rails for bed mobility.

During an interview on 04/30/25 at 3:45 PM, Licensed Practical Nurse (LPN)6 stated that there was a pre-evaluation that gave a score that indicated the need for bedrail use. She was unsure if anything was assessed or monitored prior to bedrail use. She stated a resident should not have bedrails if their assessment stated that bedrails were not indicated or should not be used. She stated she completed Resident R27's February bed rail assessment but was unaware that Resident R27 had bedrails or why the assessment stated he did not use or should not use bedrails.

During an observation and interview on 04/30/25 at 5:10 PM, LPN6 looked in Resident R27's room and stated, You sure do have bedrails. Resident R27 said he did not use them, but they have always been on the bed.

During an interview on 05/01/25 at 3:25 PM, the Director of Nursing (DON) stated staff should be screening, completing an evaluation, risk and benefits of bedrail use were explained and making sure a resident could release the bedrail by themselves. He stated nurses documented in the assessment a risk for entrapment.

He stated staff should be exploring alternatives prior to bedrail use and it was not appropriate for a resident to have bedrails if they were assessed not to.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33865

Residents Affected - Many Based on observation, record review, interview, and facility policy review, the facility failed to ensure the menu was followed regarding menu substitutions displayed on the menu and tray tickets for one of one resident (Resident (R)91) reviewed for menu compliance of 30 sample residents. This had the potential to affect nutritional status and resident preferences for residents who received food from the kitchen.

Findings include:

Review of the facility's policy titled, Menus revised 10/22, revealed, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines .

Review of Resident R91's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED], with diagnoses including but not limited to: protein-calorie malnutrition and diabetes.

Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/25, located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident R91 was cognitively intact.

Review of the Order Summary Report, located under the Orders tab of the EMR, revealed Resident R91 was on consistent carbohydrate diet (CCD) diet with start date of 07/26/24.

Review of the undated Week at a Glance menu, week one for Tuesday lunch and provided by the facility, revealed the following: Swedish meatballs, egg noodles, glazed carrots, dinner roll, and peaches. The alternate BBQ (barbeque) chicken thigh, buttered rice, spinach, and peaches.

During an observation and interview on 04/29/25 at 12:37 PM, Resident R91 confirmed she received meatballs, mashed potatoes, noodles, gravy, dinner roll, and peaches. The tray ticket revealed chicken and carrots. Resident R91 confirmed she did not receive the alternate chicken, or the carrots listed on the menu.

Review of the undated Week at a Glance menu, week one for Wednesday lunch and provided by the facility, revealed the following: Open faced roast pork sandwich, brown gravy, mashed potatoes, green beans, dinner roll, and lemon cake. The alternate Salisbury steak, brown gravy, buttered noodles, brussel sprouts, dinner roll, and lemon cake.

During an observation and interview on 04/30/25 at 12:30 PM, Resident R91 confirmed she received plain pork slice, mashed potatoes, dinner roll, green beans, gravy, and cake with icing. Her tray ticket revealed Salisbury steak. Resident R91 confirmed she did not receive the Salisbury steak.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 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 0803 Review of the undated Week at a Glance menu, week one for Thursday lunch and provided by the facility, revealed the following: Ranchers chicken thigh, black eyed peas, cabbage, dinner roll, and pumpkin pie Level of Harm - Minimal harm or (Cornbread was not displayed on the menu). The alternate on the menu was cheese quiche, cabbage was potential for actual harm written onto the menu which replaced the tomatoes and carrots were listed.

Residents Affected - Many During an observation on 05/01/25 from 9:00 AM - 12:51 PM, food preparation in the kitchen revealed they made fried small chicken drumsticks, cabbage, cornbread, black eyed peas, green beans, and pumpkin pie. There was no cheese quiche, tomatoes, dinner rolls, or carrots prepared.

Review of the undated Menu Substitution Log, weeks one-four and provided by the facility, revealed for week one: Thursday Lunch: The Rancher's chicken was substituted with fried chicken; and the tomatoes were substituted with cabbage.

During an observation and interview on 05/01/25 at 12:55 PM, Resident R91 confirmed she got chicken, cornbread, black eyed peas, chicken noodle soup, cornbread, and a cookie. She confirmed some of the food items did not match her tray ticket. The tray ticket showed a dinner roll, tomatoes, and vegetable soup.

During an interview on 05/01/25 at 10:09 AM, the Dietary Manager (DM) stated they did not make the alternate food items listed on the menu and she did not have access to change that information. She stated

they changed some of the food items based on resident preferences but were not able to change the electronic menu system. She stated three residents triggered to receive the cheese quiche because they did not want the chicken, but they did not make any quiche.

During an interview on 05/01/25 at 10:52 AM, the Dietary District Manager stated the preferences listed and

the main meal on the tray ticket were supposed to be communicated. He acknowledged an alternate was listed on the menu but not prepared.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33865

Residents Affected - Few Based on observation, record review, interview, and facility policy review, the facility failed to ensure resident preferences were followed for one of one resident (Resident (R)91) reviewed for food preferences of 30 sample residents. This had the potential to affect nutritional status and resident preferences for residents who received food from the kitchen.

Findings include:

Review of the facility's policy titled, Dining and Food Preferences, revised 10/22, revealed Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system .The individual tray assembly ticket will identify all food items appropriate for the resident/ patient based on diet order, allergies & intolerances, and preferences.

Review of Resident R91's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE REDACTED], with diagnoses including but not limited to: protein-calorie malnutrition and type two diabetes mellitus.

Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated the resident was cognitively intact.

Review of the care plan located under the Care Plan tab of the EMR, revised on 06/16/24, revealed resident was at risk for malnutrition. Interventions included: encourage adequate nutrition .provide diet as ordered.

Review of the quarterly Nutritional Risk Review, located under the Evaluation tab of the EMR, dated 05/01/24, revealed, No food preferences changes at this time.

Review of the quarterly Nutritional Risk Review, located under the Evaluation tab of the EMR, dated 09/15/24, revealed, No Food Preferences Updated.

Review of the quarterly Nutritional Risk Review, located under the Evaluation tab of the EMR, dated 12/17/24, revealed, the Food Preferences section was blank.

During an observation and interview on 04/29/25 at 12:37 PM, Resident R91 confirmed she received meatballs, mashed potatoes, pasta, gravy, roll, peaches, and chicken noodle soup. Her tray card revealed she was supposed to have gotten chicken and carrots. She stated the meatballs did not look appealing and would try to eat the fruit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 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 0806 During an observation and interview on 04/30/25 at 12:30 PM, Resident R91 confirmed she received pork, mashed potatoes, roll, green beans, gravy, and cake with icing. Her tray ticket revealed Salisbury steak. Her dislike Level of Harm - Minimal harm or revealed pork on the tray ticket. Resident R91 stated pork did not digest well. The resident confirmed she did not get potential for actual harm the right food items according to her preferences and received pork. She stated she tried to eat the mashed potatoes, but it tasted like pork, so she could not eat it. Residents Affected - Few

During an observation and interview on 05/01/25 at 12:55 PM, Resident R91 confirmed she got chicken, cornbread, black eyed peas, chicken noodle soup, cornbread, and cookies. She confirmed the food items did not match her tray ticket. The tray ticket showed a roll, tomatoes, and vegetable soup.

During an interview on 05/01/25 at 10:09 AM, the Dietary Manager (DM) and the cook stated they used the tray tickets which had preferences and food items from the menu. The DM stated they needed to double-check the preferences from the tray ticket, on the line. She stated she did not have access to change

the menu items- through the electronic menu version. She confirmed the dislikes on the tray ticket did not align with the menu items displayed on the tray tickets.

During an interview on 05/01/25 at 10:52 AM, the Dietary District Manager stated the tray tickets had a section for the preferences, and the system was supposed to incorporate the preferences and automatically change the food items. He confirmed the tray tickets were not aligned with the preferences displayed.

During an interview on 05/02/25 at 11:51 AM, the Operations Manager stated they tried to get everyone's preferences and follow the regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28154 potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure that Residents (R)34, Residents Affected - Few Resident R47, and Resident R84 or the Resident Representatives (RRs) reviewed for signing the Arbitration Agreement had the agreement clearly explained to ensure the signatories were fully aware of the consequences of signing the agreement.

Findings include:

Review of the facility's policy titled Binding Arbitration Agreements, revised November 2023, revealed: Policy Statement Residents (or representatives) are informed of the nature and implications of any proposed binding agreements so as to make informed decisions on whether to enter into such agreements. Policy Interpretation and Implementation . 5. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e., litigation). 6. The terms and conditions of a binding arbitration agreement are explained to

the resident (or representative) in a form and manner that he or she understands, taking into consideration

the resident's (or representative's) language, literacy, and stated preference for learning. 7. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or

she understands the agreement before being asked to sign the document. a. A signature alone is not sufficient acknowledgement of understand. b. The resident (or representative) must verbally acknowledge understand, and the verbal acknowledgement documented by the staff member who explains the agreement. 9. If arbitration agreements are embedded within other contracts or agreements (for example, the admission agreement), the facility will ensure that the arbitration agreement is distinguished from the other agreement and explain [sic] to the resident (or representative) that her [sic] or she may accept or decline each agreement separately. 11. Any facility personnel who are responsible for explaining the terms and conditions of binding arbitration agreements to the residents (or representatives) are trained in the specifics of this policy .

1. Review of Resident R84's Admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admitted [DATE REDACTED].

Review of Resident R84's admission Minimum Data Set (MDS) with an assessment reference (ARD) date of 04/17/25, showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of being cognitively intact.

Review of Resident R84's admission paperwork from the EMR Documents tab showed he initialed each page and signed the facility Arbitration Agreement on 04/11/25.

During an interview on 05/01/25 at 2:05 PM, Resident R84 did not remember signing an arbitration agreement stating, [They] just give you a lot of forms and you just sign. Resident R84 denied the right to go to court to settle a dispute that was being waived was made clear and did not remember anything pointed out about having 30 days to rescind his agreement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 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 0847 2. Review of Resident R47's Admission Record from the EMR Profile tab showed a facility admitted [DATE REDACTED].

Level of Harm - Minimal harm or Review of Resident R47's admission MDS with an ARD of 04/17/25 showed a BIMS score of 15 out of 15, indicative of potential for actual harm being cognitively intact.

Residents Affected - Few Review of Resident R47's admission paperwork from the EMR Documents tab showed his RR initialed each page and signed the facility Arbitration Agreement on 04/11/25.

During an interview on 05/01/25 at 2:15 PM, regarding explaining the arbitration agreement, Resident R47 along with his RP stated, The day he came in my husband came in with him. A gal came in the next day and went over everything, and I signed the paperwork but that is not something I remember that was explained or signing. When asked if he remembered anything about the arbitration agreement, Resident R47 responded No. I don't think I would have signed it.

3. Review of Resident R34's Admission Record from the EMR Profile tab showed a facility admitted [DATE REDACTED].

Review of Resident R34's admission MDS with an ARD of 03/17/25, showed a BIMS score of 15 out of 15, indicative of being cognitively intact.

Review of Resident R34's admission paper from the EMR Documents tab showed he initialed and signed the facility Arbitration Agreement on 03/11/25.

During an interview on 05/01/25 at 2:42 PM, Resident R34 stated he did not remember signing an arbitration agreement. After an explanation of what the agreement entailed, Resident R34 stated he did not remember any of that, I don't think I would have signed it.

During an interview on 05/01/25 at 2:20 PM, the Medical Records Director (MRD) confirmed she does the admission paperwork, explained the process, stating, I start out with HIPAA law, speak with them and check who is the RP and talk with them or the resident. I discuss the bed hold, 10 days for Medicaid, if insurance private or Medicare, . I talk to them about private pay.

We discuss code status, flu shots, pneumonia, and COVID vaccines, TB test and photographs here. When queried about the facility arbitration agreement and signing away rights, the MRD responded, I let them know if they sign, it's a way to protect them and handle it in house. Our facility will do the lawyer part for them instead of them having to get a lawyer on their own. Arbitration is handled in a quicker manner than on their own. They don't have to sign it; I read it to them and explain it. When asked if the arbitration agreement is signed separately, MRD stated, No, when they sign the HIPAA they sign at the end, not actually each page.

During an interview on 05/01/25 at 3:11 PM, the Human Resources Director (HRD) stated she used to do the admission paperwork, went and reviewed the arbitration agreement with the residents and RP, gave all the option to rescind and only Resident R47 wanted to do so. The HRD stated she explained to the RP she just needed a note in writing to rescind. The HRD confirmed none of them remembered going over the form upon admission.

During an interview on 05/01/25 at 5:25 PM, the General Manager stated the expectation is that we provide to the resident the [arbitration] agreement clearly explained to them in layman's terms, in a way clearly understood to the resident and/or RP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 425171