Millennium Post Acute Rehabilitation

Based on review of the facility policy, observations, and interviews, the facility failed to ensure proper tracheostomy care, in relation to documentation and changing the tracheostomy neck tie, according to professional standards of practice for 1 of 1 resident reviewed.Findings include:Review of a facility policy titled Trach Tie Change dated 01/2025, revealed Policy: The respiratory care provider should use accepted practices to change trach ties.Frequency: Every seven days, after showers or when visibly soiled.A review of the admission record revealed that the facility admitted Resident (R)4 on 09/05/2025, with diagnoses that included, but were not limited to, chronic respiratory failure with hypoxia, dependence on respiratory [ventilator] status, functional quadriplegia, and persistent vegetative state.A review of R4's Respiratory Administration Record (RAR) dated 07/01-31/2025 revealed an order to change the trach ties weekly on Thursday (Thurs) and as needed every day shift every Thurs.During a review of R4's August Medication Administration Record (MAR), the review did not reveal an order to change the tracheostomy ties.A review of R4's Care Plan, initiated 03/13/2025, revealed that R4 has a tracheostomy related to (r/t) chronic respiratory failure.

The resident also has Chronic Obstructive Pulmonary Disease (COPD).

The interventions further revealed tracheostomy care per facility protocol.A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) that was not scored.During an observation on 09/09/2025 at 01:00 PM, the RAR did not reveal the changing of tracheostomy ties, weekly.

During an interview on 09/09/2025 at 01:06 PM, Licensed Practical Nurse (LPN)4 stated, My new nursing orientation training was for 30 days.

They are responsible for changing the tracheostomy neck ties.

Respiratory does everything associated with the R4's tracheostomy.

During an interview on 09/09/20025 at 01:15 PM, Respiratory Therapist (RT)1 stated, I've worked here for 3 years. We change his tracheostomy ties every Thursday and as needed. He lays on his side and drools a lot, so we may have to change it a little more than once a week.

During an interview on 09/09/2025 at 01:36 PM, the Director of Respiratory stated, If they have skin breakdown proximity to the stoma site, the wound nurse changes the dressing.

When R4 was in and out of the hospital, the order fell off for changing the tracheostomy ties. I realized his tracheostomy ties were not being changed once I observed there was no documentation for it.

During an interview on 09/09/2025 at 02:29 PM, the Director of Respiratory stated, We do not have any documentation on trach changes for August.

During an interview on 09/10/2025 at 05:22 PM, the Director of Nursing (DON) stated, They get checked off on changing the neck ties. It is one of the things we do during our annual skills fair.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Millennium Post Acute Rehabilitation

2416 Sunset Boulevard West Columbia, SC 29169

SUMMARY STATEMENT OF DEFICIENCIES

Based on facility policy review, record review, observations and interviews, the facility failed to ensure medications were properly stored and secured for one of one resident (R)1, observed for pharmacy services.

Specifically, a cup containing Guaifenesin (Robitussin) was observed left unattended on R1's bedside table without documentation of a self-administration assessment or physician authorization.Findings include:

Review of the facility policy titled, Medication Administration: General Guidelines, with a last review date of 7/28/25 revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.

Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.

Policy further reveals, Medications are administered at the time they are prepared.

Medications are not pre-paired/pre-set/pre-crushed.

Only one patient/resident's medications are prepared and administered at a time.An observation of R1's bedside table on 9/9/25 at 11:50 AM revealed R1 had a medication cup in her bed side table with a red liquid.

During a subsequent interview, R1 revealed it was a cough medicine that a night shift nurse gave her 2 nights ago.An observation and interview with Licensed Practical Nurse (LPN)2 on 9/9/25 at 1:38 PM revealed a loose white pill tablet that had H-49 engraved on the back of the pill. H-49 Imprint is identified as Sulfamethoxazole and Trimethoprim 800 mg [milligrams] / 160 mg, commonly used to treat various bacterial infections. LPN2 revealed she does not know what the pill is, where it came from, or who it is for. LPN2 denies pulling it for R1. LPN2 was observed wasting medication.

Record review of R1's orders revealed no PRN [as needed] and or one time order for cough medication, or Sulfamethoxazole and Trimethoprim in the past 3 days.

Record review of R1's electronic health record reveals no self-medication administration assessment completed on file nor was there a provider order for R1 to self-administer medication.

During an interview with LPN1, completed on 9/10/25 at 3:37 PM, revealed the facility has standing orders for all residents from the Provider for common symptom relief, among these medications is Guaifenesin/Robitussin: 10ml/po every 8 hours as needed which is a medication used to treat a common cough/cold like symptoms.

Subsequent record review was completed with LPN1 of R1's orders revealed no standing orders for cough medication.

Further review of R1's electronic health record indicated no one time order or note indicating that the resident was ordered for and received cough medication.

Observation was then made with LPN1 of unknown red substance in the medication cup. LPN1 was able to identify the substance as Guaifenesin/Robitussin. LPN1 acknowledged that the resident should have had an order or at least a progress note indicating the use and need for the cough medication.

During an interview with the Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 9/10/25 at 3:30 PM, revealed the leadership team has emphasized that, in accordance with safe medication administration practices, nursing staff must first verify that a resident has a valid provider order for any medication.

The medication must be active on the Medication Administration Record (MAR), and provider instructions must be carefully followed prior to administration.

Following this, staff are expected to document whether the resident took the medication and record the outcome in the resident's Electronic Health Record (EHR).

The leadership team further clarified that residents should never have medications at their bedside, particularly medications that have not been prescribed. In this case, the leadership acknowledged, the nurse who administered the cough medication failed to obtain a provider order and did not adhere to the established protocols, thereby not meeting leadership's expectations for safe and compliant medication practices.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Millennium Post Acute Rehabilitation

2416 Sunset Boulevard West Columbia, SC 29169

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 09/10/2025 at 10:30 AM, the Long-Term Care (LTC) ombudsman stated, “When I went out to speak with R5. I was informed that R5 is on a diet.

The plan was for R5 to lose weight.

But then R5 started complaining that they were not giving R5 enough to eat, and the food is not good.” During an interview on 09/10/2025 at 04:17 PM, Dietary Assistant Supervisor stated, “We get a diet form from the nursing station that tell us what the diet is so they write it on a preference slip. We then try to find out what they like. We go through the meats, milks, drinks, vegetable that we have at Millennium. On the dietary slip, it also let us know what their food allergies are.

She never request more food. I know she has to have skinless meat for her heart healthy meal.

Our diet slip breaks it down to what our meals are and what they can have and what they can't have. We follow up their preferences as much as possible. R5 can also reach out to the CNA or the Nurse if they want to request a change of diet selections. If the tray is already out, we will make the changes in the system or reprint the ticket or scratch it off. If it's something they can't have I have to have permission to change their diet. We offer salads and hamburger patties.

She has an alternate menu posted in her room. I posted it myself. It is under her meal plan she has.

They can call on their phone to us directly to change their menu selection. It is in front of her bed.

She verified she can see the Menu. We have a cook after hours. I stay till six.” During an observation on 09/10/2025 at 04:39 PM, the surveyor had difficulty reading the weekly menu on the resident's wall.

During an interview on 09/10/2025 at 04:39 PM, R5 stated, “I am unable to read the menu on the wall.” During an interview on 09/10/2025 at 05:03 PM, the Dietary Assistant Supervisor stated, “My boss had a conversation with her recently. If we ask if she is ok, R5 says she is ok. I cannot speak on extra portions for her meals because I was not here. We do try our best to see if R5 enjoys their meal.” During an observation on 09/10/2025 at 05:00 PM, the Dietary Assistant Supervisor stated, “She could not see the menu on the wall.” During an observation on 09/10/2025 at 05:00 PM, the Dietary Assistant Supervisor provided the surveyor with a menu for week 2. On Wednesday (Day 11), for dinner, the menu revealed cheese enchiladas, refried beans, pico salad, fresh grapes, sugar cookies, and milk/beverage.

During an interview on 09/10/2025 at 05:05 PM, the Dietary Assistant Supervisor provided the surveyor with a menu that was changed out for Wednesday (Day 11).

The menu revealed cheese quesadilla- 1 cup, carrots-4 ounce (oz), pico salad #8 scp, fresh grapes-4oz, sugar cookie-1, skim milk/beverage-1 cup.

She could not confirm the portion sizes.

During an interview on 09/10/2025 at 07:15 PM, the Administrator stated, “R5's Resident Representative (RR) will send food that is not on her heart-healthy diet. We have educated the RR to adhere to her diet, fluid-restricted, low-sodium.

The problem is getting her to follow her diet. We are fighting that battle with what she is eating.

She DoorDash. A Registered Dietitian (RD) is here weekly.

The RD may say she has had her allotted protein for the day.

The RD tracks the daily and weekly menu.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Millennium Post Acute Rehabilitation

2416 Sunset Boulevard West Columbia, SC 29169

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review and interviews, the facility failed to employ a full-time qualified Licensed Medical Social Worker (LMSW), as required for facilities with more than 120 certified beds. 130/130 certified beds, all of which are potentially affected by the lack of a full-time LMSW to provide necessary psychosocial support and services.Findings include:Review of facility staff list revealed there is no Licensed Medical Social Worker employed in the facility.

Review of the facility census dated 9/9/25 revealed the facility was certified for 132 beds.

During an interview with the Social Services Assistant (SSA) on 09/09/25 at 1:29 PM revealed the facility's Social Services Director, who was a Social Worker (SW) left the facility around Mid-August of 2025. SSA revealed the facility has been without a SW since that time and that she has done her best to fill in the role since her departure. SSA revealed that there is a Corporate liaison that she can call if she needs help, but she is unaware of her official title or role. SSA revealed her background is that of a Certified Nursing Assistant (CNA).

During an interview with the Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 9/10/25 at 3:30 PM revealed, Social workers at the facility are responsible for scheduling care plans, handling grievances, assisting with discharge planning, and coordinating discharge and home health services.

The full-time LMSW left the facility in mid-August, and the facility has been without an LMSW since that time.

The LNHA stated that the facility is currently posting and interviewing for the position, with a candidate scheduled to complete a facility walk-through on Friday, 9/12/25.

The DON reported that the facility currently has a resource supporting the SSA. A subsequent interview revealed that this resource is an RN, not an LMSW, and confirmed that the facility is currently without a licensed medical social worker.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Millennium Post Acute Rehabilitation

2416 Sunset Boulevard West Columbia, SC 29169

SUMMARY STATEMENT OF DEFICIENCIES

be on the wrong side of the bed, leadership team reveals the call bell should have been positioned on the side accessible to the resident to ensure timely assistance and compliance with facility standards.

Leadership team reveals in this instance, the facility staff did not follow their expectations.

Facility ID: