Millwood Hospital was cited by the Centers for Medicare and Medicaid Services (CMS) for failing to uphold patient rights to care in a safe setting and failing to ensure a registered nurse supervised the nursing care plan for patients. The cited deficiencies relate to an incident in which a male patient (with a history of sexually acting out) was able to enter a room shared by two female patients, expose himself, and ask for sexual favors from them. Even though the male patient’s admission report reflected the need for “sexually acting out precautions” and nursing documentation noted his “poor impulse and coping skills,” he remained on the unit under minimal observation. On the night of the incident, he was monitored every 15 minutes, which according to hospital policy, is the “minimal level of observation for all patients.” CMS found that the hospital’s failures in the supervision of its nursing care on the night of the incident could have impacted seven other female patients residing on the unit. The male patient’s supervision level was not immediately increased following the incident; the patient was not placed on one-on-one staff observation until fourteen hours and 25 minutes later.