Millennium Post Acute Rehab: Antipsychotic Monitoring Failure - SC
The inspection, completed March 12, 2025, identified the failure to monitor target behaviors for risperidone as a deficiency affecting Resident 33, a man with schizoaffective disorder who had been re-admitted to the facility with moderate cognitive impairment. His physician order, dated October 2023, prescribed risperidone 0.5 milligrams twice daily, specifically tied to three behaviors: delusions, yelling out, and sexual comments.
Seventeen months later, the medication records for February and March 2025 contained no documented evidence linking the drug's administration to any of those specific behaviors.
When inspectors interviewed a licensed practical nurse identified as LPN7 on the evening of March 11, she said staff were supposed to document behavior monitoring directly on the medication administration record. Then she said she was unsure what specific behaviors were associated with the risperidone for this resident. Then she said more.
She told inspectors that Resident 33 had not exhibited any sexual behaviors that she was aware of. She said he did not have any delusions. He did yell out, she said. But she had not communicated any of this to a psychiatric physician or a nurse practitioner. "Staff should be notifying one of them if they were not seeing behaviors specific to the medications being prescribed," she said — describing a standard her own facility had not met.
The next morning, a second nurse, LPN6, told inspectors she also did not know what behaviors staff were supposed to be monitoring in relation to the risperidone.
Shortly after noon on March 12, the unit manager, LPN5, told inspectors she would expect to see targeted behavior monitoring for the antipsychotic in the records. Then she said it would need to be added to the medication administration record, since it wasn't there.
Later that afternoon, the Director of Nursing confirmed that staff should have been documenting behavior monitoring for the risperidone all along.
The problem the inspection surfaces is a specific one, but not a minor one. Risperidone is an antipsychotic with documented side effects including movement disorders, sedation, and increased risk of stroke and death in elderly patients with dementia-related conditions. It is prescribed in nursing homes with the understanding that its use is tied to observable, documented symptoms, and that if those symptoms change or disappear, the prescribing clinician should know. That feedback loop, in Resident 33's case, had broken down entirely.
Nobody had documented which behaviors they were tracking. One nurse knew two of the three target behaviors had stopped. She hadn't reported it. The medication kept being given.
The quarterly assessment from December 2024 noted that Resident 33 was not exhibiting any behavioral symptoms during that review period, and that he was still receiving antipsychotic medications. That combination, a clean behavioral assessment alongside an active antipsychotic order, is precisely the kind of signal that is supposed to prompt a review. There is no indication in the inspection report that it did.
The deficiency was cited at a level of minimal harm or potential for actual harm, which is the lower end of the citation scale. The facility had 22 residents in the total sample. Inspectors reviewed five for unnecessary medications. One had this problem.
Resident 33 has schizoaffective disorder, a serious psychiatric diagnosis, and his medication was prescribed by a physician for documented reasons. None of that is in dispute. What is in dispute is whether the people administering that medication every morning and every evening knew what they were looking for, and whether anyone in the building was making sure the drug was still doing what it was ordered to do.
By the time inspectors asked, the answer was no, and no.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Millennium Post Acute Rehabilitation from 2025-03-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 8, 2026 · Our methodology
Millennium Post Acute Rehabilitation in West Columbia, SC was cited for violations during a health inspection on March 12, 2025.
Then she said she was unsure what specific behaviors were associated with the risperidone for this resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.