Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Millennium Post Acute Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain proper laundry disinfection when the laundry boiler was malfunctioning and wash temperatures were only 62 to 65 degrees Fahrenheit, while staff used Oxi-Clean in loads and were unsure of the required hot water temperature. The facility also failed to ensure proper hand hygiene and PPE use during med pass: an LPN touched a resident and administered oral meds and eye drops without appropriate glove changes and hand hygiene, and another LPN administered insulin after handling room surfaces with the same gloves.
PASARR screening was not completed before admission for two residents reviewed. One resident had diagnoses including chronic respiratory failure, DM2, MDD, and anxiety disorder, and another had rheumatoid arthritis, mood disorder, anxiety disorder, schizophrenia, and MDD. The SSD said the facility was redoing incorrectly completed PASARR Level 1s after admission, and the DON stated Level 1 PASARRs are required for entry and Level 2s are needed for certain psychiatric histories.
A resident’s wheelchair was observed with a brown leaf and visible white stains on the back and wheels on repeated checks. The resident had diagnoses including muscle wasting atrophy, unsteadiness on feet, pain in the left hip, stiffness of joint, muscle weakness, and difficulty walking, and was cognitively intact with a BIMS score of 13/15. Staff gave differing accounts of wheelchair cleaning practices, and the DON and DOLLS both observed the wheelchair was visibly dirty.
A facility with over 120 certified beds failed to employ a full-time qualified LMSW after the previous Social Services Director left. Since then, a Social Services Assistant with a CNA background has attempted to fill the role, with some support from a corporate liaison and an RN, but no licensed social worker was on staff. This left all residents potentially affected by the lack of required psychosocial support and services.
Staff failed to secure PHI for two residents by leaving sensitive documents uncovered in a clear mailbox accessible to others and by leaving a computer unattended in a common area with a resident's face sheet visible. Facility leadership confirmed these actions were not in line with HIPAA or facility policy.
A resident with chronic respiratory failure and ventilator dependence did not receive tracheostomy tie changes as required by facility policy, and there was no documentation of these changes for an entire month. Staff interviews confirmed that the order for trach tie changes was not consistently maintained or documented, leading to a lapse in care.
A resident was found with an unattended cup of Guaifenesin (Robitussin) at the bedside, and a loose pill of Sulfamethoxazole and Trimethoprim was discovered without documentation or provider orders. Nursing staff could not account for the medications, and no self-administration assessment or authorization was present. Facility policy requiring provider orders, proper documentation, and secure storage of medications was not followed.
A resident with multiple chronic conditions was placed on a heart-healthy, consistent carbohydrate diet but reported dissatisfaction with repetitive meals and an inability to read the posted menu. Staff interviews confirmed the menu was not legible to the resident, and there was uncertainty about meal portion sizes. Despite efforts to accommodate preferences, the facility failed to ensure the resident received a nourishing, palatable, well-balanced diet that met both nutritional needs and personal preferences.
A resident with significant mobility impairments was found unable to reach the call bell, which had been placed on the opposite side of the bed. The resident experienced severe pain and was unable to request assistance for over 15 minutes. An LPN confirmed the call bell was out of reach, and staff interviews revealed that facility policy requires call bells to be accessible at all times, but this expectation was not met, resulting in a delay in care.
A resident with end-stage renal disease and type 2 diabetes did not receive prescribed medications and nutritional supplements on dialysis days. The LPN confirmed the resident missed doses, and the physician was not notified. The NP acknowledged the orders should have indicated medication administration during dialysis, but they did not. The DON could not provide expectations on ensuring staff followed physician orders, indicating a lack of oversight.
A resident, totally dependent on staff and unable to voice needs, fell from bed due to inadequate supervision by an LPN and a distracted CNA. The resident coughed and slid off the bed, resulting in facial swelling and redness. The facility's root cause analysis failed to accurately identify the events leading to the fall, highlighting a lapse in adherence to the facility's fall management policy.
A resident with significant weight loss did not receive the physician-ordered Mighty Shakes with meals due to a communication failure between the Registered Dietician and the Dietary Manager. Observations and staff interviews confirmed the absence of the supplement on the resident's meal trays, placing the resident at risk for further weight loss.
A resident's clinical records were found to be incomplete and inaccurately documented, as the resident did not receive a prescribed nutritional supplement, Mighty Shakes, with meals despite records indicating otherwise. Observations confirmed the absence of the supplement, and interviews with LPNs revealed reliance on CNAs for verification, leading to documentation inaccuracies. The DON acknowledged the issue with one LPN's practices.
The facility failed to develop a comprehensive care plan for a resident with anoxic brain damage and a guardian, neglecting to address the mother's interference with care and the need to contact her after notifying the guardian. The DON revealed that the mother's language barrier led to a misunderstanding about the resident's catheter, which was resolved without a care plan in place.
Infection Control Failures in Laundry Sanitization and Medication Administration
Penalty
Summary
The facility failed to ensure linen and resident clothing were washed at appropriate temperatures or with proper disinfection in the laundry room. During observation, the industrial washing machine was running at 62 to 65 degrees Fahrenheit, and the laundry assistant confirmed that reading. The assistant stated he was not sure of the proper hot water temperature for laundry and also reported that the laundry room boiler had been a problem. The laundry room was observed with chemical products connected to an automatic dispensing system, including bleach, sour/softener, alkali, and detergent. Further review and interviews showed the boiler supplying hot water to the laundry room had been malfunctioning for about 2.5 weeks and was leaking water from the bottom of the tank. The maintenance assistant reported the riser thermometer gauge read 64 degrees Fahrenheit and the water heater thermometer gauge read 65 degrees Fahrenheit. The maintenance/life safety director stated the boiler had been malfunctioning from time to time, that a new boiler had been ordered, and that when the current boiler worked the temperature was between 140 and 160 degrees Fahrenheit. The laundry attendant stated she had been using 1.5 to 2 cups of Oxi-Clean Versatile Stain Removal in each laundry load since the boiler had been malfunctioning. The infection preventionist stated she had been made aware of the boiler being out of order a few weeks earlier but was not aware it was still out of order and was not aware of the Oxi-Clean product being used. The facility also failed to ensure medications were administered using proper hand hygiene and PPE during medication pass for two residents. One LPN entered a resident's room on Enhanced Barrier Precautions, touched the bed control and the resident's face and head with bare hands while positioning the resident for oral medications, and did not wear gloves for those actions. In another observation, the same LPN administered eye drops and oral medication to a resident on Enhanced Barrier Precautions, removed gloves after the eye drops, but did not perform hand hygiene before giving the oral medication or before putting on a new pair of gloves for a second eye drop. A second LPN applied gloves before entering another resident's room, closed the privacy curtains and room door with gloved hands, and then administered insulin without removing the gloves or performing hand hygiene. The DON stated she could not defend the nurse touching environmental surfaces and giving insulin with the same gloves, and the infection preventionist stated the nurses should remove gloves and perform hand hygiene before entering the room, after touching environmental surfaces, and before administering medication.
PASARR Screening Not Completed Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed prior to admission for 2 of 7 residents reviewed. The facility did not have a policy related to PASARR assessments. Review of one resident’s face sheet showed admission with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder, and the resident’s PASARR Level 1 was completed by the facility after admission. Review of another resident’s face sheet showed admission with diagnoses including rheumatoid arthritis, mood disorder, anxiety disorder, schizophrenia, and major depressive disorder, and that resident’s PASARR Level 1 was also completed by the facility after admission. During interview, the SSD stated she was checking all PASARR Level 1s because they had not been completed correctly, and that the department was having to redo the PASARRs. She stated there had been pushback from hospitals about completing them, so her department had been correcting them by reviewing hospital records and obtaining information from the resident and/or family. The SSD also stated that a licensed social worker or nurse can complete a Level 1, while a Level 2 has to be completed with a physician. The DON stated that Level 1 PASARRs are required for entry into the facility and Level 2s are required if there had been a recent psychiatric stay or diagnosis, and that if the facility did not receive a Level 1 prior to entry, the facility social worker could complete it or try to obtain one from the hospital or community.
Dirty Wheelchair Observed for Resident 1
Penalty
Summary
The facility failed to ensure Resident 1’s adaptive equipment was clean. Resident 1 was admitted with diagnoses including muscle wasting atrophy, unsteadiness on feet, pain in the left hip, stiffness of joint, muscle weakness, and difficulty walking. The quarterly MDS showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact, and also documented that the resident used a wheelchair. During observations, Resident 1’s wheelchair leaf was noted to be brown, with white stains visible on the back of the wheelchair and on the wheels. The same condition was observed again the following day. Staff interviews revealed differing practices for wheelchair cleaning, including housekeeping cleaning wheelchairs at least monthly, daily sanitizing if the chair was empty, and cleaning as needed when soiled. The Director of Housekeeping and Laundry Services later acknowledged visible debris on the wheelchair and stated the last cleaning had occurred several days earlier. The DON also observed that the wheelchair was visibly dirty.
Failure to Employ Full-Time LMSW in Facility with Over 120 Beds
Penalty
Summary
The facility failed to employ a full-time qualified Licensed Medical Social Worker (LMSW) as required for facilities with more than 120 certified beds. Record review showed that the facility was certified for 132 beds, but there was no LMSW employed at the time of the survey. The Social Services Director, who was a social worker, left the facility in mid-August, and since then, the facility has been without a licensed social worker. The Social Services Assistant (SSA), whose background is as a Certified Nursing Assistant (CNA), has been attempting to fill the role in the interim, with some support from a corporate liaison whose official title and role were unclear to the SSA. Interviews with facility leadership, including the Administrator, DON, and ADON, confirmed that the responsibilities of the social worker included scheduling care plans, handling grievances, assisting with discharge planning, and coordinating discharge and home health services. It was further confirmed that the facility had no LMSW on staff at the time of the survey, and the resource currently supporting the SSA was an RN, not an LMSW. All 130/130 certified beds were potentially affected by the absence of a full-time LMSW to provide necessary psychosocial support and services.
Failure to Secure Resident PHI in Public Areas
Penalty
Summary
The facility failed to maintain the confidentiality and security of resident Protected Health Information (PHI) for two residents. Specifically, a resident's code status document containing PHI was observed uncovered and unsecured in a clear wall-mounted mailbox located in a hallway accessible to staff, residents, and visitors. Additionally, documents such as advance directives and a signed Do Not Resuscitate order were left exposed in the same mailbox, making sensitive information easily accessible and not in compliance with facility policy. Further, a staff member left a computer on wheels (COW) unattended in a common area with the screen displaying a resident face sheet, including the resident's name, photograph, and medical details. The Assistant Director of Nursing was observed later securing the computer and closing the resident's chart. Interviews with facility staff and leadership confirmed that these actions were not in accordance with facility policy or HIPAA regulations, and that PHI should not have been left visible or unattended in these areas.
Failure to Ensure Proper Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to ensure proper tracheostomy care for a resident with chronic respiratory failure, ventilator dependence, functional quadriplegia, and a persistent vegetative state. According to facility policy, tracheostomy ties should be changed every seven days, after showers, or when visibly soiled. The resident's Respiratory Administration Record included an order to change the trach ties weekly and as needed, but the August Medication Administration Record did not reflect this order. Observations and interviews revealed that there was no documentation of tracheostomy tie changes for the month of August, and staff confirmed that the order for changing the ties had lapsed when the resident was in and out of the hospital. Interviews with staff, including an LPN, a respiratory therapist, and the Director of Respiratory, indicated that while the responsibility for changing the tracheostomy ties was understood, the actual documentation and consistent performance of this task were lacking. The Director of Respiratory acknowledged the absence of documentation and noted that the issue was only discovered upon review. The DON stated that staff are checked off on this skill during annual training, but this did not ensure ongoing compliance with the required frequency of tracheostomy tie changes or proper documentation.
Failure to Secure and Document Medication Administration
Penalty
Summary
Facility staff failed to ensure that medications were properly stored and administered according to policy and professional standards. During an observation, a medication cup containing a red liquid identified as Guaifenesin (Robitussin) was found unattended on a resident's bedside table. The resident reported that the cough medicine was given by a night shift nurse two nights prior. There was no documentation of a self-administration assessment or a provider order authorizing the resident to self-administer medication. Additionally, a loose white pill identified as Sulfamethoxazole and Trimethoprim was found, with no staff able to account for its origin or intended recipient, and no corresponding order in the resident's records for either medication in the preceding three days. Review of the resident's electronic health record confirmed the absence of any provider order or documentation for the administration of cough medication or Sulfamethoxazole and Trimethoprim. Interviews with nursing staff and facility leadership revealed that the nurse who administered the cough medication did not obtain a provider order and failed to document the administration or the need for the medication. Facility policy requires that medications be administered only with a valid provider order, be documented in the Medication Administration Record, and not be left at the resident's bedside. These protocols were not followed in this instance, resulting in the deficiency.
Failure to Ensure Resident Receives Palatable, Well-Balanced Diet Respecting Preferences
Penalty
Summary
The facility failed to ensure the nutritional well-being of a resident while also respecting the individual's right to make choices about their diet. The resident, who had diagnoses including chronic respiratory failure, tracheostomy status, COPD, and hypertensive heart disease, was placed on a heart-healthy, consistent carbohydrate diet with specific restrictions. Despite having an intact cognitive status, the resident reported dissatisfaction with the repetitive nature of the meals, specifically mentioning frequent servings of chicken and occasional meals without meat. The resident also expressed a lack of understanding about the heart-healthy diet and reported not being able to read the posted menu in their room. Interviews with staff revealed that dietary preferences were supposed to be accommodated through a preference slip and that an alternate menu was posted in the resident's room. However, both the surveyor and the resident confirmed that the menu was not legible to the resident. The Dietary Assistant Supervisor acknowledged the issue and stated that while efforts were made to accommodate preferences and provide alternatives, changes to the diet required permission, and there was uncertainty about portion sizes for certain meals. The staff also indicated that the resident could request changes through CNAs or nurses, but the resident had not requested more food. Further, the administrator noted challenges with the resident and their representative bringing in outside food and not adhering to the prescribed diet, despite education efforts. The Registered Dietitian monitored the resident's intake and menu compliance, but the resident continued to express dissatisfaction with the food provided and the lack of variety. These actions and inactions led to a failure to provide a nourishing, palatable, well-balanced diet that met the resident's nutritional and personal preferences, as required by regulation.
Call Bell Inaccessibility Leads to Delay in Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for self-care and mobility due to muscle weakness and a history of cerebral infarction, was found in bed with the call bell positioned out of reach on the opposite side of the bed. The resident, who had impairment in both lower extremities, was unable to access the call bell and reported being in significant pain, rating it as 8 out of 10. The resident stated she had been trying to get staff attention for over 15 minutes to request pain medication but was unable to do so due to the call bell's placement. During the observation, a Licensed Practical Nurse confirmed that the call bell was not within the resident's reach and acknowledged that facility policy requires call bells to be accessible to all residents at all times. The facility's policy and staff interviews indicated that staff are expected to ensure call bells are within reach before leaving a resident's room and to conduct regular rounding. In this instance, these expectations were not met, resulting in a delay in care for the resident.
Failure to Administer Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure that all medications were appropriately administered on dialysis days for a resident with end-stage renal disease and type 2 diabetes. The resident, who had significant cognitive impairment, was scheduled to attend hemodialysis on Tuesdays, Thursdays, and Saturdays. However, the Medication Administration Record revealed that the resident's medications, including Midodrine and Sevelamer, as well as a nutritional supplement, were not regularly administered on these days. This oversight was confirmed during an interview with an LPN, who admitted that the resident missed the second dose of blood pressure medication and the nutritional supplement on dialysis days, and the physician was not notified of these missed medications. Further interviews revealed a lack of clarity and communication regarding medication administration during dialysis times. The Nurse Practitioner acknowledged that while it was understood that dialysis residents did not receive medications during dialysis, the orders should have reflected this, which they did not. The Director of Nursing was unable to provide information or expectations on ensuring staff followed physician orders for medication administration, indicating a gap in oversight and communication within the facility. This deficiency highlights a failure in the facility's processes to ensure residents receive their prescribed treatments consistently.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in a fall from bed. The resident, who was totally dependent on staff for activities of daily living and unable to voice her needs due to a tracheostomy, was being cared for by an LPN and a CNA when the incident occurred. The resident coughed and slid off the bed, landing on her right side, which led to swelling and redness on her face. The resident was sent to the emergency room for evaluation, where it was determined that no head or neck injury was sustained. The root cause analysis conducted by the facility was inadequate, as it failed to accurately identify the events leading to the fall. The LPN reported turning the resident towards the CNA, who did not have her hands on the resident at the time of the fall. The CNA admitted to being distracted and unable to prevent the fall. The facility's policy on fall management emphasizes the importance of providing an environment free of accident hazards and adequate supervision, which was not adhered to in this case.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident identified as having significant weight loss. The resident, who was moderately cognitively impaired, was ordered by a medical provider to receive Mighty Shakes, a nutritional supplement, with meals. However, observations and interviews revealed that the resident did not receive the supplement as ordered. The resident's meal trays did not include the Mighty Shake, and the meal tickets did not list it, indicating a failure in communication and implementation of the dietary order. Interviews with staff, including CNAs, LPNs, and the Dietary Manager, confirmed that the order for the Mighty Shakes was not communicated to the kitchen. The Registered Dietician stated that a report was supposed to be sent to the Dietary Manager, but this communication was missed, resulting in the resident not receiving the necessary nutritional supplement. This oversight placed the resident at risk for further weight loss, as the dietary intervention was not implemented as per the physician's order.
Inaccurate Documentation of Nutritional Supplement Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for one resident, identified as R75. The deficiency was identified during a review of R75's medical records, which revealed that the resident was ordered a nutritional supplement, Mighty Shakes, with meals. However, observations on two separate occasions showed that the resident did not receive the Mighty Shake with their meals, despite documentation in the Medication Administration Record (MAR) indicating that the supplement was provided. Interviews with staff, including LPN1 and LPN8, revealed inconsistencies in the process of verifying and documenting the consumption of the Mighty Shake. LPN1 admitted to relying on CNAs to confirm whether the resident consumed the supplement, rather than verifying it personally. The Director of Nursing acknowledged the issue, attributing it to LPN1's documentation practices, but denied any fraudulent documentation by all nurses. This failure to ensure accurate documentation had the potential to impact the resident's care.
Failure to Develop Comprehensive Care Plan for Resident with Guardian and Family Interference
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with anoxic brain damage and persistent vegetative state. The resident's electronic health record indicated that the guardian should be notified before the mother in case of any changes. However, the care plan did not include instructions regarding the mother's interference with care or the need to contact her after notifying the guardian. The Social Services Director and the MDS Nurse both confirmed that they do not typically care plan for guardianship or family interference issues. The Director of Nursing revealed that the resident's mother, who has a language barrier, was trying to communicate concerns about the resident's catheter size. This led to a misunderstanding where staff thought she was interfering with the catheter. The issue was resolved by using a language line and adjusting the catheter size, but this situation highlighted the lack of a care plan addressing who to contact and when. Additionally, the mother's contact information was not listed in the resident's paperwork.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Opus Post Acute Rehabilitation | 0.9 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare - Lexington | 1 mi | ★★★★★ | 1 | 0 |
| Presbyterian Home Of South Carolina-columbia | 1.9 mi | ★★★★★ | 0 | 0 |
| Still Hopes Episcopal Retirement Community | 2.9 mi | ★★★★★ | 0 | 0 |
| St Andrews Operator, Llc | 3.7 mi | ★★★★★ | 0 | 0 |
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