Millennium Post Acute Rehab: Resident Fall Violations - SC
The incident happened January 31 at Millennium Post Acute Rehabilitation on Sunset Boulevard, and federal inspectors documented it during a March 12 survey. The resident, identified in inspection records as R109, was fully dependent on staff for all care. According to the facility's Therapy Program Manager, she had no capacity to initiate movement in her bed or to remain on her side on her own.
LPN1 was repositioning R109 at the time, turning the resident toward CNA4, who was stationed on the other side of the bed specifically to receive her. LPN1 said she turned the resident, the resident coughed hard, and slid off the bed. CNA4 did not grab her.
The Director of Nursing told inspectors the correct technique was to use a draw sheet to pull a resident toward the staff member, not push the resident away. That is what LPN1 had done. The problem was what happened on the other side.
CNA4's own account, relayed through the unit manager LPN2, was direct: she told him she was distracted, and by the time the resident began to fall, it was too late.
LPN2, who managed the unit, said the Assistant Director of Nursing had provided CNA4 with education on bed mobility after the incident. The ADON also told inspectors this was the first time LPN1 had been present for a resident fall during her employment there.
Inspectors tried three times to reach CNA4 directly. They left calls and messages. She never responded.
When inspectors observed R109 on the morning of March 11, she was in bed with fall mats placed on both sides. She did not move while they watched. The mats were there because of what had already happened, not because of anything she could do herself.
The facility's own interdisciplinary team had reviewed the fall and completed a root cause analysis. The DON, when interviewed, said she was not the staff member who conducted it. The inspection report does not identify who did.
What the root cause analysis documented was straightforward: two staff members were present, one on each side of a resident who could not protect herself, and the resident fell anyway. The cough was not the cause. A cough is not an unexpected event in a care facility. A dependent resident coughing while being repositioned is a foreseeable moment, the kind of moment CNA4 was there to handle.
The deficiency was cited at a level of minimal harm or potential for actual harm, among the lower tiers of federal severity classifications. R109 was returned to bed by LPN1 after the fall. The inspection report does not describe injuries.
By the time inspectors arrived six weeks later, R109 was still there, still in bed, still dependent on staff for everything, with foam mats on the floor on either side of her.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
The incident happened January 31 at Millennium Post Acute Rehabilitation on Sunset Boulevard, and federal inspectors documented it during a March 12 survey.
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.