Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Midlands Health & Rehabilitation Center during CMS and state inspections, most recent first.
Four residents were not offered the COVID-19 vaccine booster, and there was no documentation of education or consent regarding the vaccine in their medical records. The facility's policy required tracking and documentation of vaccination status, but this was not completed due to staff turnover and lack of follow-through.
Wet bowls and plates were stacked for lunch service before they had properly air-dried, and some still contained food remnants. The DM confirmed the items were wet and stated they should not be stacked wet because of the increased risk of bacteria growth.
The facility did not notify the Ombudsman of the discharge of two residents who were transferred to a hospital for care that could not be provided at the facility. Although internal procedures assigned responsibility for notification to the Social Worker, the Ombudsman's office reported not receiving any transfer or discharge reports from the facility for several months.
MDS incorrectly coded a resident’s medication status. Record review showed the resident had a stroke diagnosis and was ordered Clopidogrel (Plavix), an antiplatelet, but the quarterly MDS documented an anticoagulant. The MDSC confirmed the resident was taking an antiplatelet and that the MDS was miscoded.
Dirty Oxygen Concentrator Filters: The facility failed to clean oxygen concentrator filters for 3 residents receiving respiratory care. One resident had chronic respiratory failure with orders for continuous O2 via trach collar and weekly filter cleaning, while two other residents had O2 orders via NC or HFNC. During observation, the ADON confirmed each concentrator filter was coated with dirt and dust and stated the filter should be cleaned weekly to improve air flow and decrease the risk of bacteria.
An LPN left a medication cart unlocked and unattended in the hallway while preparing meds and entering another resident's room, with a resident sitting in front of the cart. Facility policy required medications to be stored securely in locked compartments and accessible only to authorized staff, and the Administrator stated carts must be locked whenever staff walk away from them.
Glucometers were not disinfected between resident uses when an LPN completed accuchecks on two residents and placed the device back on the med cart without cleaning it. The LPN confirmed she skipped cleaning the glucometer between residents, despite being trained to disinfect the device before and after each use. Facility leadership stated staff are trained to clean patient care equipment and use Sani-Cloths or bleach wipes for Accu-Chek devices.
The facility failed to remove expired medications from use, with expired drugs found in medication carts and rooms. Discontinued and discharged residents' medications were improperly stored, and personal snacks were found on a medication cart. These issues were confirmed by nursing staff and the ADON, highlighting non-compliance with the facility's medication disposal and storage policies.
A resident with multiple health conditions was transferred to the hospital for respiratory distress without proper notification to her or her representative. The facility's documentation lacked necessary details, such as the reason for the transfer, and there was no evidence that the resident or her representative received a copy of the transfer notice. Staff interviews revealed inconsistencies in the documentation process.
A facility failed to provide a resident or their representative with a timely copy of the Bed Hold Policy following a hospital discharge. The resident, admitted with severe medical conditions, was transferred to the hospital for respiratory distress. Despite the facility's policy requiring the policy to be given before or within 24 hours of hospitalization, there was no documentation confirming this was done.
A resident with severe cognitive impairment and multiple health conditions was not provided with an ongoing program of activities tailored to her interests and preferences. Observations showed the resident was consistently in bed without activities, despite a care plan indicating a need for one-to-one visits involving music and reading. Activity records revealed infrequent engagement, and the resident's preferences for gospel music and religious services were not accommodated.
A facility failed to ensure residents were free from electrical hazards, resulting in an Immediate Jeopardy situation. One resident, with diagnoses including depression and heart failure, and another resident, diagnosed with anxiety disorder and morbid obesity, were involved. A CNA overheard calls for help due to a smoking and sparking bed, leading to the evacuation of the residents. The Fire Department confirmed a damaged bed cord, though no fire occurred. Interviews revealed that staff observed sparks and smoke, and the Maintenance Director was unavailable for comment. The Administrator noted a lack of documentation on routine preventive maintenance for electric beds.
Failure to Offer and Document COVID-19 Vaccine Booster for Residents
Penalty
Summary
The facility failed to ensure that four residents were offered the COVID-19 vaccine booster, as required by both facility policy and CDC recommendations. Record reviews revealed that for these residents, either the COVID-19 vaccination status was listed as 'pending consent' without further documentation, or there was no information regarding immunization status in the medical record. Care plans for these residents indicated a risk for infections and a need for vaccinations, but there was no evidence that education about the COVID-19 vaccine or an offer to receive the booster was provided or documented. Interviews and policy reviews confirmed that the facility was responsible for tracking and documenting vaccination status, including providing education about the benefits and risks of the vaccine. The administrator acknowledged that frequent turnover in the infection preventionist role contributed to the failure to identify and offer COVID-19 immunizations or boosters to the affected residents. There was no documentation in the records of these residents indicating that they or their representatives had been informed or given the opportunity to consent to the vaccine.
Wet Dishes Stored Before Air-Drying
Penalty
Summary
The facility failed to ensure kitchen staff thoroughly cleaned and air-dried plates and bowls before storing them for use during lunch service. Review of the facility policy on storage and cleaning of dishes and utensils stated that clean dishes, silverware, pots, pans, and utensils are to be stored in a clean dry area, air dried before storing, and not dried with a towel. During an observation and interview, the Dietary Manager confirmed that 10 four-ounce bowls stacked on the food service line and 20 plates stacked in the plate warmer were wet and some contained food remnants. The Dietary Manager stated the plates and bowls had not properly dried prior to stacking and should not be stacked wet because of the increased risk of bacteria growth.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of the discharge of two residents who were transferred to an acute care hospital. Review of facility policy indicated that written notice of transfer or discharge should include the name, address, and telephone number of the State Ombudsman, but the policy did not specify that the Ombudsman must be notified of the transfer or discharge itself. Record review showed that one resident was initially admitted with a need for care that could not be provided by the facility, and another resident had a primary diagnosis of chronic respiratory failure and also required care beyond the facility's capabilities. Notices of transfer or discharge were completed for both residents. Interviews with facility staff revealed that the process for notifying the Ombudsman involved the Social Worker running a monthly report of all transfers and discharges and sending notifications to the Ombudsman's office. However, the Ombudsman Program Assistant confirmed that no transfer or discharge reports had been received from the facility since March, despite the facility's internal process and staff responsibilities. The lack of documentation and confirmation of Ombudsman notification for the two residents' transfers resulted in the deficiency.
MDS Incorrectly Coded Anticoagulant Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met for one resident, R7, whose quarterly MDS with an ARD of 06/16/25 documented that he was receiving an anticoagulant. Record review showed R7 was admitted and re-admitted to the facility with diagnoses including cerebral infarction (stroke), and the physician order in the EMR showed he was taking Clopidogrel (Plavix), which is an antiplatelet medication. During interview, the MDS Coordinator stated that R7 was taking an antiplatelet medication and not an anticoagulant, and that the MDS was miscoded and needed to be corrected.
Dirty Oxygen Concentrator Filters
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to clean respiratory equipment for 3 of 4 residents reviewed for respiratory care. The facility policy titled Equipment Rounds General stated that veinlet filters on oxygen concentrators shall be visually inspected and cleaned or replaced as necessary, but the oxygen concentrator filters for R6, R87, and R68 were observed coated with dirt and dust. R6 had diagnoses including chronic respiratory failure and had physician orders for 2 lpm of O2 with humidity on a trach collar continuously, as well as an order to clean and check concentrator/compressor filters weekly on Mondays and as needed. R87 had diagnoses including asthma and chronic heart failure and an order for O2 at 2 lpm via nasal cannula every shift, but no order for cleaning the concentrator filter was found. R68 had a diagnosis including respiratory failure and an order for high-flow nasal cannula therapy with 2 lpm O2 concentrator every shift, but no order for cleaning the concentrator filter was found. During observations and interviews, the ADON confirmed each resident's oxygen concentrator was coated with dirt and dust and stated the filter should be cleaned weekly to improve air flow and decrease the risk of bacteria.
Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure that 1 of 4 medication carts was properly secured and locked. Facility policy titled, Pharmacy Services Policies and Procedures: Medication Storage, stated that medications and biologicals are to be stored safely and securely in locked compartments and accessible only to licensed nursing personnel, pharmacy personnel, or authorized staff members. During observation, an LPN was preparing medications to administer to a resident when another resident asked for a blood glucose check. The LPN left the medication cart unlocked and unattended in the hallway while she entered another resident's room, and the cart remained unlocked and in view with the resident sitting in front of it until the LPN returned. The LPN stated she usually locks the cart but was in a hurry and forgot. The Administrator stated that staff must keep the medication cart locked if they walk away from it for any period of time.
Glucometers Not Disinfected Between Resident Uses
Penalty
Summary
The facility failed to ensure glucometers were disinfected after use for 2 residents, R96 and R46, during blood glucose monitoring. During observation on 09/10/25, LPN1 used an Accu-Chek glucometer in R96's room and then placed the device in the top right drawer of the med cart without sanitizing it. Later that same day, LPN1 used the glucometer on R46 and again placed it on top of the med cart without cleaning it. LPN1 confirmed she did not clean the glucometer between the two residents and stated she was in a hurry to administer medications and that sometimes the devices are put away without cleaning them. She also confirmed she had been trained to clean glucometer devices before and after each use and between residents with alcohol wipes by her agency. Review of the facility's policy stated equipment would be maintained and kept sanitized or disinfected in accord with acceptable policies. The facility's matrix dated 09/08/25 showed 13 residents received accuchecks, and none had bloodborne pathogens or diseases. During interview, the ADON/Infection Preventionist stated patient care equipment should be cleaned before and after and in between use on residents, and that staff are trained to use bleach wipes inside med carts. The Administrator stated staff are trained during orientation, quarterly, annually during skills checkoff competencies, and as needed, and that Accu-Chek devices are cleaned with purple top Sani-Cloths and allowed to air dry for two minutes.
Expired Medications and Improper Storage Practices Identified
Penalty
Summary
The facility failed to ensure that expired medications were removed and not stored with other medications in use for residents. This was observed in three out of four medication carts and two out of two medication rooms. Specifically, expired medications such as Levetiracetam, Basaglar Kwik Pen, Lispro Kwik Pen, Geri Care Saline Nasal Spray, Lorazepam, Vancomycin, Fluconazole, Baclofen, and Symbicort inhaler were found in various locations within the facility. These expired medications were confirmed by the nursing staff and the Assistant Director of Nursing (ADON) and subsequently removed from storage. Additionally, the facility did not ensure that medications that were discontinued or belonged to discharged residents were not stored in the North Hall medication room. The cabinets in this room contained three shelves full of blister packs of such medications, which were not being monitored for the 60-day period required before they could be returned to the pharmacy. The ADON was unaware of who was responsible for monitoring these medications. Furthermore, personal snacks were improperly stored on the North Hall front medication cart, including an opened cherry coke and a pack of cheese Ritz crackers. These items were confirmed and removed by the nursing staff. The facility's policy on medication disposal and storage was not adhered to, leading to these deficiencies being identified during the survey.
Failure to Provide Proper Transfer Notification
Penalty
Summary
The facility failed to provide timely and appropriate notification to a resident and her responsible party regarding a transfer to the hospital. The resident, who was admitted with severe sepsis, Alzheimer's, dementia, schizophrenia, atrial fibrillation, diabetes mellitus, and hypertension, was transferred to the hospital for respiratory distress. However, there was no documentation in the medical record to confirm that the resident or her representative received written notice of the transfer, including the reason for the transfer, in a language they could understand. The facility's policy requires that written information be provided to the resident and their representative at the time of transfer, including the reason for the transfer, the effective date, and the location to which the resident will be transferred. Despite this, the forms provided by the facility lacked necessary details, such as the reason for the transfer, and there was no evidence that the resident or her representative received a copy. Interviews with the facility's staff, including the Administrator and a Registered Nurse, revealed inconsistencies in the documentation process, as no completed checklist was provided for the resident's discharge to the hospital.
Failure to Provide Timely Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to a resident or their representative in a timely manner following a discharge to the hospital. The resident, who was admitted with severe sepsis with septic shock, Alzheimer's, dementia, acute respiratory failure, and pneumonia, was transferred to the hospital for respiratory distress. The facility's policy requires that the Bed Hold Policy be given to the resident or their representative before the resident leaves for hospitalization or within 24 hours in the case of an emergency hospitalization. Upon review of the medical records, it was found that there was no documentation to confirm that the resident or their representative received the Bed Hold Policy during the hospitalization period. An interview with the Administrator revealed that although a copy of the policy was dated and included the resident representative's name, there was no evidence to ensure it was provided within the required timeframe. This oversight led to a deficiency in adhering to the facility's policy and state requirements for temporary leave bed-hold notifications.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and preferences of a resident, identified as R20, who was admitted with severe cognitive impairment and multiple health conditions, including muscle wasting and end-stage renal disease. Observations over several days revealed that R20 was consistently in bed without any activities being provided. Interviews with the resident's personal representative and the Activity Director confirmed that R20 was not engaged in activities, despite the resident's care plan indicating a need for one-to-one visits involving music and reading to support her emotional, intellectual, physical, and social needs. The activity attendance records for June, July, and August showed infrequent and inconsistent engagement, with R20 receiving minimal interaction and no group activities or social interactions. The Activity Director acknowledged that R20 could be moved to a geri chair and potentially participate in social activities, but this was not facilitated. Additionally, the resident's preference for gospel music and religious services was not accommodated, and there was a lack of documentation regarding the resident's response to activities or the duration of these interactions.
Electrical Hazard Leads to Immediate Jeopardy Situation
Penalty
Summary
The facility failed to ensure that Resident (R)1 and R2 were free from electrical hazards, leading to an Immediate Jeopardy situation. R1, admitted with diagnoses including depression, heart failure, and cognitive communication deficit, was at risk for respiratory complications. R2, diagnosed with anxiety disorder, absence of right leg below knee, and morbid obesity, was cognitively intact. A report indicated that CNA1 overheard R2 calling for help as the bed was smoking and sparking, prompting staff to evacuate the residents. The Fire Department confirmed a damaged cord from the bed, with no actual fire reported. During interviews, R2 described witnessing flames and zapping sounds, while RN1 reported seeing sparks and smoke coming from under R1's bed. CNA1 recalled moving both residents to safety upon seeing smoke in the room. The Maintenance Director was unavailable for interview, and the Administrator acknowledged a lack of documentation on routine preventive maintenance for electric beds.
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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 Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth- Columbia | 0.8 mi | ★★★★★ | 0 | 0 |
| Forest Acres Post Acute | 0.8 mi | ★★★★★ | 0 | 0 |
| C M Tucker Jr Nursing Care Center Fewell And Stone | 1.9 mi | ★★★★★ | 1 | 1 |
| C M Tucker Jr Nursing Care Center Roddey Pavilio | 1.9 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Columbia | 2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.