Millwood Hospital was cited by the Centers for Medicare and Medicaid Services (CMS) for multiple deficiencies following a complaint investigation survey. CMS cited the facility’s governing body for failing to follow its policies to provide a safe setting and failing to uphold patient’s rights to care in a safe setting. The cited deficiencies relate to two separate patient incidents. The first of which involved the improper physical restraint of a 6-year old boy while he was placed in seclusion. A staff member was attempting to restrain the young patient alone, and was not provided assistance, nor was a staff member present to observe the patient for signs of distress. Video surveillance showed that the staff member was sitting on the bed with his legs wrapped around the patient while the patient wriggled and struggled. Due to the incorrect hold, the patient fell face down and sustained a nasal fracture. CMS also found that the facility failed to provide a safe setting for two adolescent female patients who were threatened and forced to engage in improper sexual activities with a male staff member. Interviews with the Chief Executive Office and the Risk Management Director confirmed that male staff are not allowed on the adolescent female unit, yet according to CMS, “none of the nurses or staff questioned why a male staff was on the adolescent unit.” CMS review of facility investigation documents revealed that despite this prohibition, the staff member was observed to be on the adolescent female unit multiple times during and after his shift. As a result, the facility was required to submit a plan of correction to address its cited deficiencies, which included retraining staff on restraint and seclusion techniques and revision of its deficient policies.