Millennium Post Acute Rehabilitation

F-F842

Findings include:

Review of the facility's policy titled, Dietary Services, dated 05/2014, indicated . The RD [Registered Dietician] or designee will document the specific interventions used and determine a monitoring system to evaluate the success of the interventions initiated (i.e. weekly eights, food/fluid intake studies, etc.) .

Review of Resident 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 REDACTED].

Review of Resident 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 Resident 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 Resident 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, Resident 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, Resident 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, Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 425105 Department of Health & Human Services Printed: 09/04/2025 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 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

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 0692 During an interview on 03/11/25 at 8:36 AM, CNA3 stated Resident R75 did not receive a Mighty Shake with his meals, and it would be on his meal ticket if he did. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/11/25 at 10:09 AM, Licensed Practical Nurse (LPN) 2, who was the unit manager for [NAME] and Camillia units, stated when the medical providers ordered Mighty Shakes, a diet slip was Residents Affected - Few created and taken to the kitchen.

During an interview on 03/11/25 at 10:11 AM, the Dietary Manager (DM) stated the kitchen supplied the Mighty Shakes for the residents and confirmed that she had never received an order from the nurses for Resident R75.

During an interview on 03/12/25 at 10:50 AM, the RD stated the medical provider did order Resident 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 Resident R75.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 425105 Department of Health & Human Services Printed: 09/04/2025 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 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

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12679

Residents Affected - Few Based on record review, interviews, and facility policy review, the facility failed to ensure that clinical records were complete and contained accurate documentation for one of 22 residents (Resident (R)75) whose records were reviewed. This had the potential for the resident not to receive accurate care.

Findings include:

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 Resident 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 REDACTED].

Review of Resident 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 Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 425105 Department of Health & Human Services Printed: 09/04/2025 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 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

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 0842 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 Level of Harm - Minimal harm or fraudulently. The DON stated it was an issue with LPN1. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 425105