Midlands Health & Rehab: Documentation Failures - SC
Federal inspectors found the facility failed to offer boosters to residents aged 6, 16, 25, and 46 during a September complaint investigation. The administrator blamed "multiple turnovers for the infection preventionist role" for the oversight.
The facility's own policy, revised in May 2023, required staff to track all resident vaccination status and document education provided about "benefits and potential risks associated with the COVID-19 vaccine." Records showed no evidence any of the four residents received this education or were offered boosters.
CDC recommendations reviewed by inspectors called for adults over a certain age to receive two or more doses of the 2024-2025 vaccine. Younger adults should receive at least one dose of the updated vaccine.
Resident 6, who had been at the facility since her original admission date, showed a care plan updated September 10 that identified her as "at risk for infections with need for vaccinations." But her preventive health care record from November 20, 2024 listed her COVID-19 vaccine status as "Other - pending consent."
The same pattern appeared for Resident 16. His care plan, also updated September 10, noted infection risk and vaccination needs. His November 20, 2024 preventive health record showed identical status: "Other - pending consent."
Resident 25's case was worse. Her care plan from August 18 didn't include any immunization status. Her preventive health care tab contained no information at all about COVID-19 vaccination.
Resident 46's September 10 care plan identified infection risk and vaccination needs, but her preventive health record from November 19, 2024 showed "Other - pending consent" for COVID-19 vaccine status.
None of the four residents had documentation showing they were offered vaccines or boosters, despite the facility's written commitment to educate residents and track their vaccination decisions.
The inspection report noted this failure created "potential for the residents and/or their responsible party of not being informed to make a decision if they wanted the vaccine and a potential risk of contracting COVID-19."
During her interview with inspectors on September 11 at 5:55 PM, the administrator acknowledged the documentation gaps. She confirmed there was no evidence in any of the four residents' records showing they were offered COVID-19 vaccines or boosters.
The administrator pointed to staffing problems in the infection control department. Multiple people had cycled through the infection preventionist position, she said, contributing to the facility's failure to identify which residents needed vaccination offers.
The facility's policy spelled out exactly what should happen. Staff were supposed to document vaccination education in residents' medical records, including the date education was provided and the name of any representative involved in the decision.
But months passed with residents' vaccination status stuck at "pending consent" without any follow-up documented in their records.
Resident 25's case stood out for the complete absence of vaccination information. While the other three residents at least had outdated entries showing pending consent status, her preventive health care section was empty.
The CDC recommendations inspectors reviewed emphasized the importance of updated vaccinations, particularly for older adults who face higher risks from COVID-19. The 2024-2025 vaccine schedule incorporated Health and Human Services directives about vaccination recommendations for different age groups.
Federal inspectors classified the violation as having potential for actual harm to residents. The failure affected four of the five residents whose records were reviewed during the investigation.
The administrator's explanation highlighted a common problem in nursing homes: critical safety functions disrupted by staff turnover. But the facility's policy didn't include exceptions for staffing changes, and residents remained unprotected while management sorted out personnel issues.
All four residents had care plans identifying them as at risk for infections and needing vaccinations. The disconnect between documented risk and actual vaccination offers represented a breakdown in the facility's infection control system at a time when COVID-19 continued circulating in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Midlands Health & Rehabilitation Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Midlands Health & Rehabilitation Center in Columbia, SC was cited for violations during a health inspection on September 11, 2025.
Federal inspectors found the facility failed to offer boosters to residents aged 6, 16, 25, and 46 during a September complaint investigation.
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.