Midlands Health & Rehabilitation Center

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, interview, and facility policy review, the facility failed to ensure that the Ombudsman was notified of 2 residents (Resident (R)56 and Resident R93) discharge to an acute care hospital out of a sample of 26 residents. This failure increased the risk for inappropriate transfer or discharge and increased the risk for the resident having access to an advocate who could inform them of their options and rights.Findings include:Review of the facility's policy and procedures titled, Admission, Discharge and Transfer - Code of Ethics revised on 10/23/19 indicated . The written notice of transfer or discharge includes: . The name, address, and telephone number of the State Ombudsman . The policy did not include Ombudsman notification of the transfer/discharge.Review of Resident R56's Face Sheet in the Electronic Medical

Record (EMR) under the Resident tab indicated he was initially admitted to the facility on [DATE REDACTED].Review of Resident R56's Notice of Transfer or discharge date d 07/31/25, provided by the facility, indicated that Resident R56 required immediate care which could not be provided by the facility.Review of Resident R93's Face Sheet in the EMR under

the Resident tab indicated she was initially admitted to the facility on [DATE REDACTED] with a primary diagnosis of chronic respiratory failure.Review of Resident R93's Notice of Transfer or discharge date d 06/11/25, provided by the facility, indicated that Resident R93 required immediate care which could not be provided by the facility.During an

interview on 09/10/25 at 6:41 PM, the Administrator revealed that the previous Social Worker (SW) was employed by the facility up until August 2025 and that she had been responsible for notifying the Ombudsman of resident transfers/discharges. The Administrator stated no paper copy was kept, but she had an email that was sent to the Ombudsman's office on 09/09/25 requesting confirmation that the previous SW had provided monthly transfer/discharge notifications.During a follow up interview on 09/11/25 at 4:25 PM, the Administrator stated that when sending a resident to the hospital, the nurse was to complete a Notice of Transfer or Discharge and the Ombudsman's office was to be notified at the beginning of the month of any discharges for the prior month. The Administrator provided an email dated 09/09/25 that

the Human Resources (HR) staff emailed the Ombudsman's office requesting confirmation from their office to determine if the previous SW had been sending monthly transfer/discharge notifications.During an

interview on 09/11/25 at 10:33 AM, the Ombudsman Program Assistant reported that they had not received any transfer/discharge reports from the facility since March 2025.During an interview on 09/11/25 at 4:30 PM, the Business Office Manager (BOM) stated that she was to fill out the Notice of Transfer or Discharge form, send a copy of the forms with the resident to the hospital, and then send a copy to the Responsible Party. The Social Worker would then run a report at the beginning of the month for the month prior for all transfers/discharges. The SW was to send notification to the Ombudsman's office.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Midlands Health & Rehabilitation Center

1007 N King St Columbia, SC 29223

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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, review of the Centers for Disease and Prevention (CDC) recommendations, and facility policy review, the facility failed to ensure that 4 residents (Resident (R)6, Resident R16, Resident R25, and Resident R46) out of 5 reviewed, were offered the COVID-19 vaccine booster out of a total sample of 26 residents. This failure had the potential for the residents and/or their responsible party of not being informed to make a decision if

they wanted the vaccine and a potential risk of contracting COVID-19.Findings include:Review of the facility's policy titled, Infection Prevention and Control Policies and Procedures Subject: Immunization recommendations for patients/residents and health care workers revised 05/15/23 indicated .The facility will track all staff and resident vaccination status for the COVID-19 vaccine. Resident vaccination status will be documented in their medical record and include: 1) Education provided to the resident or resident representative regarding the benefits and potential risks associated with the COVID-19 vaccine (including date and name of representative) .Review of CDC recommendations for 2024-2025 COVID-19 vaccinations located at cdc.gov/covid/vaccines/stay-up-to-date.html as of May 29, 2025, the schedule incorporates the HHS [Health and Human Services] directive regarding COVID-19 vaccine recommendations . for adults 19-26, 27-29, and 50-64 was to receive one or more doses of 2024-2025 vaccine and for adults older than [AGE] years of age should receive two or more doses of 2024-2025 vaccine .Review of Resident R6's Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab indicated that she was originally admitted to the facility on [DATE REDACTED]. Resident R6 was [AGE] years old.Review of Resident R6's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included Resident R6 being at risk for infections with need for vaccinations.Review of Resident R6's Preventive Health Care tab located in the EMR indicated that on 11/20/24 the COVID-19 vaccine status was Other - pending consent.Review of Resident R16's Face Sheet located in

the EMR under the Resident tab indicated that he was originally admitted to the facility on [DATE REDACTED]. Resident R16 was [AGE] years old.Review of Resident R16's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included Resident R6 being at risk for infections with need for vaccinations.Review of Resident R16's Preventive Health Care tab located in the EMR indicated that on 11/20/24 the COVID-19 vaccine status was Other - pending consent.Review of Resident R25's Face Sheet located in the EMR under the Resident tab indicated that she was admitted to the facility on [DATE REDACTED]. Resident R25 was [AGE] years old.Review of Resident R25's Care Plan located in the resident's EMR under the Care Plan tab and updated 08/18/25 did not include an immunization status.Review of Resident R25's Preventive Health Care tab located in the EMR had no information.Review of Resident R46's Face Sheet located in the EMR under the Resident tab indicated that she was admitted to the facility on [DATE REDACTED]. Resident R46 was [AGE] years old.Review of Resident R46's Care Plan located in the resident's EMR under the Care Plan tab and updated 09/10/25 included Resident R46 being at risk for infections with need for vaccinations.Review of Resident R46's Preventive Health Care tab located in the EMR indicated that on 11/19/24 the COVID-19 vaccine status was Other - pending consent.During an interview on 09/11/25 at 5:55 PM, the Administrator stated she felt that multiple turnovers for the infection preventionist role contributed to the lack of identification of COVID-19 immunizations and/or boosters not being offered. The Administrator confirmed there was no evidence in the four residents' (Resident R6, Resident R16, Resident R25, and Resident R46) records of being offered a COVID-19 vaccine or booster.

Event ID:

Facility ID:

If continuation sheet