Cycle 1
Health 2025-03-12 · Fire 2025-03-12
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
West Columbia, SC
Millennium Post Acute Rehabilitation
1-star overall rating with 2-star inspections with $4,271 in total fines with 11 recent health deficiencies
2416 Sunset Boulevard, West Columbia, SC
(803) 796-8024
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1976-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
1.34
Licensed practical nurse staffing
Aide hours / resident day
2.09
Nurse aide staffing
Weekend hours
3.31
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
57%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.9
0.5 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
90.5%
9.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
90.6%
7.8 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.0%
1.9 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.9%
2.9 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.0% |
6.2%
7.8 pts worse
|
5.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
20.4%
4.5 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
16.3%
2.2 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 1.6% |
0.2%
1.4 pts worse
|
0.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.9% |
14.9%
4 pts better
|
16.3%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
12.4%
8.2 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.7%
0.6 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.6%
1.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
17.2%
2.2 pts worse
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 21.9% |
5.8%
16.1 pts worse
|
5.1%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
79.8%
18.3 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
14.1%
3.3 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.6%
0.4 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
78.0%
17.7 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
24.7%
6.7 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-02-10 · Fire 2022-02-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-26
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-10
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-08
D · Potential for more than minimal harm
2024-03-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-01-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-01-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-23
F · Potential for more than minimal harm
2022-02-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-12
E · Potential for more than minimal harm
2022-02-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-12
E · Potential for more than minimal harm
2022-02-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-03-12
D · Potential for more than minimal harm
2022-02-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-03-12
D · Potential for more than minimal harm
2022-02-10
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-03-12
Penalties and ownership
What sits behind the stars
$4,271
2024-01-26
Fine
Fine · fine $4,271
Fine
Ownership
Hopewell Healthcare, Inc.
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Burton, Spencer
Corporate Officer · Individual
Christensen, Christopher
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Port, Barry
Corporate Officer · Individual
Snapper, Suzanne
Corporate Officer · Individual
Willits, Adam
Operational/Managerial Control · Individual
Wittekind, Beverly
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Opus Post Acute Rehabilitation
West Columbia, SC
2-star overall rating with 2-star inspections with $12,043 in total fines with 5 recent health deficiencies
#2
NHC Healthcare - Lexington
West Columbia, SC
3-star overall rating with 2-star inspections with 4 recent health deficiencies
#3
Presbyterian Home Of South Carolina-Columbia
Lexington, SC
5-star overall rating with 4-star inspections with 3 recent health deficiencies
Jump out