Millennium Post Acute Rehabilitation

During an observation on 03/11/25 at 8:51 AM, R109 was in bed and had a fall mat on each side of her bed.

The resident did not move while in bed.

During an interview on 03/11/25 at 1:21 PM, LPN1 stated she was in the room along with CNA4 when the fall occurred. LPN1 stated she turned the resident towards CNA4, and CNA4 was present but did not grab the resident, the resident then coughed and then fell from the bed. LPN1 checked on the resident, placed her back into bed, and then informed her manager of the incident.

During an interview on 03/11/15 at 2:40 PM, the Therapy Program Manager (TPM) stated the resident did not have the capacity to initiate movement in her bed or to remain on her side.

Three calls and messages were left for CNA4, and there were no returned calls received.

During an interview on 03/12/25 at 8:35 AM, the Director of Nursing (DON) stated she was not the staff member who completed the root cause analysis.

The Assistant Director of Nursing (ADON) stated this was the first time LPN1 had experienced a resident fall while she worked with them.

During an interview on 03/12/25 at 2:16 PM, LPN2, who was the unit manager for the [NAME] and Camillia Units, stated his understanding of R109's fall was LPN1 reported she had turned the resident towards CNA4, and CNA4 did not have her hands on the resident. LPN2 stated the ADON provided education to CNA4 regarding bed mobility. LPN2 stated CNA4 told him she was distracted and when the resident began to fall, it was too late to grab her.

During an interview on 03/12/25 at 2:47 PM, the DON stated the staff were taught to use the draw sheet to pull the resident towards them and not to push the resident away from the staff member.

The DON stated R109 was totally dependent on staff for all cares.

425105 03/12/2025

Millennium Post Acute Rehabilitation 2416 Sunset Boulevard West Columbia, SC 29169

During an interview on 03/12/25 at 10:50 AM, the RD stated the medical provider did order R75 Mighty Shakes since he was losing weight.

The RD stated the process was for her to make the recommendation, an order was written, and a report was sent to the DM in addition to the order.

The RD stated the DM missed her communication for the Mighty Shake for R75.

425105 03/12/2025

Millennium Post Acute Rehabilitation 2416 Sunset Boulevard West Columbia, SC 29169

Review of R33's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Continuity of Care (CCD) tab, indicated the resident was re-admitted to the facility on [DATE] with diagnoses including schizoaffective disorder.

Review of R33's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/24 and located under the MDS tab in the EMR -, indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R33 was moderately cognitively impaired.

The assessment indicated the resident was not exhibiting any behavioral symptoms during the assessment period. It also indicated that the resident used antipsychotic medications during the assessment period.

Review of R33's Physician Order Report, dated 10/04/23 and found in the EMR under the Orders Tab, indicated R33 was to receive risperidone 0.5 milligrams (mg), one tablet by mouth twice daily for schizoaffective disorder as evidenced by delusions, yelling out, and sexual comments.

Review of R33's Medication Administration Record (MAR), dated February and March 2025 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific behaviors were associated with the administration of the resident's antipsychotic medications and required routine monitoring.

During an interview on 03/11/25 at 5:35 PM, Licensed Practical Nurse (LPN)7 stated staff documented monitoring of target behaviors on a resident's medication MAR.

She stated she was unsure what specific behaviors were associated with the risperidone for R33.

She stated R33 had not had any sexual behaviors that she was aware of, but he did yell out.

She stated he did not have any delusions, but she had not communicated that with anyone.

She stated she had not reported that to psychiatric physician or the nurse practitioner. LPN7 stated staff should be notifying one of them if they were not seeing behaviors specific to the medications being prescribed.

During an interview on 03/12/25 at 9:59 AM, LPN6 stated staff document behavior monitoring on a resident's MAR.

She stated she was unsure of what the behaviors were that staff should be monitoring in relation to R33's risperidone.

During an interview on 03/12/25 at 12:02 PM, LPN5, who was a unit manager, stated she would expect to see monitoring of the targeted behaviors for R33's antipsychotic medications. LPN5 stated it would need to be added to the MAR since it was not indicated on there.

During an interview on 03/12/25 at 3:18 PM, the Director of Nursing (DON) stated staff should be documenting they are monitoring targeted behaviors for R33's risperidone.

425105 03/12/2025

Millennium Post Acute Rehabilitation 2416 Sunset Boulevard West Columbia, SC 29169

Review of a facility policy titled, Physician Orders, Telephone Orders and Recapitulation Process .

Documentation in Long Term Care Record, dated 08/2016, indicated, .

This policy ensures that the hybrid record during the transition to the EHR (electronic health record) is managed in accordance with the requirements for maintaining the designated record set. It is the policy of this facility to ensure accuracy of the physician orders, as much as possible, in accordance with the state and federal regulations.Physician's orders shall be obtained prior to the initiation of any medication or treatment .

Review of R75's Face Sheet, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE].

Review of R75's Physician Orders, located under the Orders tab and dated 01/23/25, indicated the resident was ordered Mighty Shakes (nutritional supplement) with meals.

Review of R75's Medication Administration Record, located under the Orders tab of the EMR and for the months of 01/2025, 02/2025, and 03/2025, indicated the order for the Mighty Shake was transcribed into the MAR section and revealed documentation the resident received his physician order Mighty Shake with each meal since 01/23/25.

Two observations were conducted of R75. An observation was conducted on 03/10/25 at 12:35 PM, and the resident did not have Mighty Shake on his lunch tray. An observation was conducted on 03/11/25 at 8:32 AM, and there was not a Mighty Shake on his breakfast tray.

The resident stated he was to have a Mighty Shake on his trays but did not receive it.

During an interview on 03/11/25 at 8:37 AM, Licensed Practical Nurse (LPN)1 stated the process for ordering the Mighty Shake was to complete a diet slip and send it to the kitchen. LPN1 was shown her documentation from 03/10/25 and 03/11/25, and she stated she was to make sure that the resident actually drank the Mighty Shake and typically will ask the Certified Nurse Aide (CNA) if the Mighty Shake was consumed by the resident. LPN1 stated she needed to actually verify that the resident drank a Mighty Shake or not.

During an interview on 03/12/25 10:02 AM, LPN8 stated the Mighty Shakes came from the kitchen.

LPN8 stated she would ask the CNA if the resident drank the shake and then document this information in the MAR.

During an interview on 03/12/25 at 2:47 PM, the Director of Nursing (DON) stated that it was stressed with all clinical staff to enter accurate information into the clinical records and denied that all nurses documented fraudulently.

The DON stated it was an issue with LPN1.

Review of R75's Face Sheet, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE].

Review of R75's Care Plan, located under the Care Plan tab of the EMR and dated 05/18/22, indicated the resident had the potential for weight loss and would refuse being weighed at times.

The goal identified on the care plan was to provide a physician ordered diet.

Review of R75's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/24 and located in the ASPEN MDS viewer, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired.

The assessment indicated the resident did not sustain any significant weight loss.

Review of R75's Physician Orders, located under the Orders tab of the EMR and dated 01/23/25, indicated the resident was identified with significant weight loss, and the medical provider ordered to add Mighty Shakes (nutritional supplement) with meals.

During an interview on 03/10/25 at 11:51 AM, R75 stated he was aware that he was losing weight, but he was unsure why.

During an observation on 03/10/25 at 12:35 PM, R75 had his meal tray on his bedside table and there was no Mighty Shake on his tray. At 1:14 PM, Certified Nurse Aide (CNA)1, pulled the resident's tray from the meal cart, and confirmed that the resident did not receive a Mighty Shake.

During an observation on 03/11/25 at 8:32 AM, R75's meal tray was observed and there was no mighty shake on his tray.

The resident's meal ticket was reviewed during this observation, and there was no Mighty Shake listed on his meal ticket.

During an interview on 03/11/25 at 8:33 AM, CNA2 stated the Mighty Shakes came from the kitchen, and if the resident was ordered the shake, it would be on his tray.

425105

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 425105 B.

Wing 03/12/2025

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

Millennium Post Acute Rehabilitation 2416 Sunset Boulevard West Columbia, SC 29169