Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Cheraw Healthcare during CMS and state inspections, most recent first.
Missing Annual CNA Competency Evaluations: The facility failed to ensure and document annual competency evaluations for 5 of 5 CNAs reviewed. Facility policy required competency evaluations during orientation, annually, and as needed, but personnel records showed no annual evaluations within the required timeframe. The HR Director and Administrator both confirmed the evaluations had not been completed as required.
Failure to provide routine hair and nail care: A resident with severe cognitive deficits, stroke history, and an ADL self-care deficit was observed over multiple days with dirty fingernails and hair that was dirty and matted. The care plan called for assistance with bathing and personal hygiene, but the resident remained unclean until the concern was brought to the attention of the assigned LPN.
Failure to attempt a GDR for a resident with Alzheimer's dementia who was receiving Quetiapine 200 mg HS. The resident had severe cognitive impairment, low body weight, weight loss, and multiple falls, and the MRR recommended considering a dose reduction. The physician chose to maintain the dose, but the record lacked resident-specific clinical rationale for not reducing the antipsychotic.
Expired Aspirin was found in a medication cart with in-date medications in 1 of 4 carts reviewed. The facility policy assigned nursing staff responsibility for maintaining medication storage and preparation areas, and an LPN confirmed the expired bottle during observation and removed it from the cart.
Out-of-range nourishment refrigerator temperatures were observed in the North Unit Hall-100 nourishment room. The refrigerator held resident supplements, juices, and personal food items, and the temperature gauge read 46 degrees F, above the facility’s required 41 degrees F limit. Records showed repeated elevated readings over several days, and interviews with the KM, Maintenance Director, and Administrator confirmed the issue had been reported and that the refrigerator and thermometer had been replaced or changed, but temperatures remained out of range.
A resident with severe cognitive impairment was mistakenly given medications intended for her roommate by an RN, leading to symptoms such as hypotension and diaphoresis, and requiring hospitalization for drug overdose. The incident was compounded by a lack of documented vital sign monitoring in the medical record, and was cited as a significant medication error under pharmacy services.
Expired medications and biologicals were found in two medication storage rooms. In the South Unit, an LPN verified and removed an expired BD Vacutainer Red Top. In the North Unit, the DON confirmed and removed an expired BD Vacutainer Gel and Lithium Heparin Top, expired Covidien Filac Probe Covers, and expired Covidien Kangaroo Epump Sets. These findings indicate a failure to follow the facility's policy on proper storage.
The facility failed to ensure accurate documentation of Advance Directives for several residents, leading to discrepancies between hard charts and EMRs. One resident's DNR order was missing from the EMR, while another had conflicting code status information. Staff interviews revealed issues with the transition to a new electronic system, contributing to the documentation gaps.
A facility failed to complete a restraint assessment for a resident using a trunk restraint on a wheelchair. The resident, who is severely cognitively impaired, was observed with a lap n lock padded lap desk, but no documentation of an assessment or consent was found in their records. Staff confirmed the absence of necessary documentation, and a late entry assessment and unsigned consent form were later provided. The resident's representative did not recall consenting to the restraint.
A resident with severe intellectual disabilities and oropharyngeal phase dysphagia was observed lying flat during tube feeding, contrary to the facility's policy requiring a 45 to 90-degree elevation to prevent aspiration. An LPN corrected the positioning after acknowledging the error, and the DON confirmed the expectation for proper bed elevation.
A facility failed to provide proper respiratory care for a resident with COPD due to the absence of a policy for cleaning and storing nebulizer equipment. Observations revealed the nebulizer machine and oxygen mask were not properly cleaned or stored, and the oxygen concentrator was set incorrectly. The DON confirmed the correct procedure was not followed.
A resident with cognitive impairment and mobility issues experienced multiple falls due to the facility's failure to implement effective fall prevention measures. Despite the resident's history of falls, interventions such as using a nonskid pad or locking wheelchair brakes were not consistently applied, leading to incidents where the wheelchair rolled away during transfers.
Missing Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure and document annual performance evaluations for 5 of 5 Certified Nursing Assistants reviewed. Review of the undated facility policy titled Skill Competency Evaluations showed that nurses and CNAs were to have competency evaluations completed during orientation, annually, and as needed by designated staff. However, review of personnel records for all 5 CNAs found no documentation of an annual performance evaluation within the required timeframe. During interviews, the Human Resource Director confirmed that annual competency evaluations had not been completed for the CNAs reviewed, and the Administrator confirmed that although competency evaluations were required annually for nurses and CNAs, they had not been completed as required.
Failure to Provide Routine Hair and Nail Care
Penalty
Summary
The facility failed to ensure a resident received needed assistance with activities of daily living, specifically routine hair and nail care. The resident had diagnoses including anxiety disorder, cerebral infarction, and a history of urinary tract infections, and the MDS showed a BIMS score of 4 out of 15, indicating severe cognitive deficits. The care plan identified an ADL self-care performance deficit related to fatigue, impaired balance, and stroke, and included interventions for extensive assistance with bathing, dressing, transfers, and partial/moderate assistance with personal hygiene and oral care. During observations, the resident was found in bed with dirty fingernails and hair in need of washing, and on subsequent observations the fingernails and hair remained unclean, with the hair described as dirty and matted to the head. The resident’s RP was present feeding the resident during one observation. The Administrator stated she would speak with the nurse about why the resident was not bathed and clean daily. The assigned LPN stated she was not aware the resident had not received a bath on any of the three days observed, and after the concern was brought to attention, the resident’s hands and fingernails were cleaned and the hair was shampooed.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident with diagnoses including Alzheimer's dementia, cognitive communication deficit, and anxiety who was receiving Quetiapine 200 mg at bedtime. The resident's MDS showed a BIMS score of 4 out of 15, indicating severe cognitive deficit. The facility policy stated that residents receiving psychotropic medications should receive GDRs when clinically appropriate unless contraindicated, and that documentation must support when dose reductions are attempted or when there is a clinical rationale for not attempting a reduction. The resident's physician order showed Quetiapine 200 mg nightly had been ordered on admission. The medical record also showed a weight of 86 pounds and documented a history of significant weight changes, along with multiple falls, including a fall with minor injuries, a fall with a left femur fracture, another fall with minor injuries, and a fall with right hip pain. A medication regimen review dated 11/21/2025 recommended evaluating the current dose and considering a dose reduction, but the physician responded, "Resident with good response, maintain the current dose," without resident-specific documentation or clinical rationale for not reducing the dose. During interviews, the pharmacist stated she had recommended a reduction and the physician declined, and the attending physician acknowledged that 200 mg of Seroquel was a large dose for the resident's weight and agreed the weight loss and falls could have been attributed to Quetiapine.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from use and kept separate from in-date medications in 1 of 4 medication carts. During review of the facility policy titled, Medication Labeling and Storage, the nursing staff was identified as responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation of the South Hall medication cart #1, surveyors found one bottle of Aspirin 325 mg tablets, Lot #921X06, that had expired on 01/26/2026. An LPN confirmed the expired medication during interview and removed the bottle from the medication cart.
Out-of-Range Nourishment Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that food stored in the North Unit Hall-100 nourishment room refrigerator was maintained at a safe temperature. During observation, the refrigerator temperature gauge read 46 degrees Fahrenheit and was verified by the kitchen manager. The refrigerator contained nine Mighty Shakes, two Medpass supplement drinks, five Glucerna Shakes, eight Ardmore 100% Orange Juices, and residents' personal food items. The facility policy stated that nourishment room refrigerators are to be maintained at 41 degrees Fahrenheit or below, with daily temperature checks and documentation. Record review showed repeated out-of-range temperatures in the North nourishment refrigerator over multiple days, including readings of 52, 50, 44, 42, 48, and 46 degrees Fahrenheit. Interviews with the kitchen manager, maintenance director, and administrator confirmed the refrigerator temperatures had been out of range and that the issue had been reported to maintenance. The maintenance director stated the refrigerator had been replaced on 02/19/26 and that the thermometer had been changed more than once because the temperature remained out of range. The administrator stated she was not aware the refrigerator temperatures were out of range until informed during the survey.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive deficits was administered medications intended for her roommate. The error took place after the RN had already prepared the medications for the roommate and, while assisting the resident in the restroom, inadvertently gave her the wrong medications. The medications administered included morphine sulfate, quetiapine fumarate, Eliquis, clonidine, docusate sodium, carvedilol, atorvastatin, hydralazine, and gabapentin, none of which were prescribed for the resident who received them. Following the administration of the incorrect medications, the resident exhibited symptoms including feeling sick, a weak pulse, hypotension, and diaphoresis. The RN recognized the error and began monitoring the resident, who subsequently required emergency medical attention. The nurse notified the Unit Manager, who instructed her to contact the physician. The resident was transported to the emergency department, where she was treated for drug overdose and received Narcan and intravenous fluids. The facility's documentation revealed that vital signs were not recorded in the medical record as expected. Both the DON and Unit Manager confirmed that there was no documentation of the resident's vital signs during the incident, despite the expectation that such monitoring should be documented. The incident was determined to be a significant medication error and was cited under pharmacy services for substandard quality of care.
Removal Plan
- MD notified and Resident was sent to the hospital. Resident returned with no adverse effects.
- All residents were assessed by the Director of Nursing with all residents without distress. Vital signs obtained and reviewed for abnormalities, none noted. All residents assessed by Director of Staff Development.
- Roommate MAR reviewed for medication administration. Resident received medications as ordered.
- Resident's names placed outside doors and pictures placed on EMR on every resident. Identification bracelets placed on all residents.
- Inservice on Medication Administration, Medication Errors Policy & Procedures was completed.
- Director of Staff Development and/or designee to provide skills competency to each nurse before next scheduled shift.
- DON to monitor medication administrations skills competencies until compliance has been met.
Expired Medications and Biologicals Found in Storage Rooms
Penalty
Summary
The facility failed to remove expired medications and biologicals from two medication storage rooms, as observed during a survey. In the South Unit's medication storage room, a BD Vacutainer Red Top with an expiration date of 09/30/24 was found. This expired item was verified by an LPN and subsequently removed. In the North Unit's medication storage room, a BD Vacutainer Gel and Lithium Heparin Top with an expiration date of 10/31/24 was discovered. The Director of Nursing (DON) confirmed its expiration and removed it. Additionally, two boxes of Covidien Filac Probe Covers with an expiration date of 08/31/24, each containing 20 probe covers, and one box containing 19 probe covers were also found expired and removed by the DON. Further observations in the North Unit's hallway medication storage revealed three Covidien Kangaroo Epump Sets with Flush 1000 ml, expired since 03/31/23, and one set with an expiration date of 07/31/24. The DON verified these items as expired and removed them from storage. These findings indicate a failure to adhere to the facility's policy of storing medications and biologicals safely, securely, and properly, as per manufacturers' recommendations or those of the supplier.
Inaccurate Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents had accurate and documented Advance Directives, affecting five out of eight residents reviewed. The facility's policy stated that residents have the right to make informed decisions about their medical care, including the right to formulate advance directives. However, discrepancies were found between the residents' hard charts and electronic medical records (EMR), leading to confusion about their code status. For instance, one resident was admitted with a diagnosis of Alzheimer's disease and unspecified dementia. Although a Do Not Resuscitate (DNR) order was found in the resident's hard chart, there was no corresponding code status in the EMR. This inconsistency was confirmed by an LPN, who acknowledged the absence of a code status order in the EMR and stated that an order would be entered. Similarly, another resident's care plan indicated a DNR status, but no physician order was found in the EMR, highlighting a gap in documentation. Additionally, a resident with severe cognitive impairment had conflicting information between their hard chart and EMR regarding their code status. The hard chart indicated a DNR order, while the EMR listed the resident as Full Code. Interviews with staff revealed that the facility had transitioned to a new electronic system, which contributed to the discrepancies. The Director of Nursing and Assistant Director of Nursing expressed expectations for timely updates to the EMR, but acknowledged issues with the transition process.
Failure to Document Restraint Assessment for Resident
Penalty
Summary
The facility failed to complete a restraint assessment for the use of a trunk restraint on a wheelchair for a resident, identified as R47, who was one of four residents reviewed for restraint use. R47, who has severe cognitive impairment with a BIMS score of 3 out of 15, was observed using a lap n lock padded lap desk as a trunk restraint. The resident's medical records did not contain documentation of an assessment for the use of this restraint, which could potentially be considered a restraint. The facility's policy requires orders and assessments for any physical restraints, but these were not found in R47's records. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed the absence of a restraint assessment and consent documentation for R47. The restraint was reportedly implemented after a fall to minimize further injury, but the necessary documentation was not completed or located. The DON later provided a late entry assessment and a handwritten consent form, which lacked a signature and was noted as telephone consent. The resident's representative also did not recall consenting to the use of a restraint. The facility's failure to properly document and assess the use of the restraint led to the deficiency noted in the report.
Improper Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure proper positioning for a resident during tube feeding, which posed a potential risk for aspiration. The facility's policy on gastrostomy tube feeding, revised on 10/10/19, outlines the necessity of placing residents in a Fowler's position to reduce the danger of aspiration. However, during an observation, Resident 107 was found lying on their right side with the bed flat while receiving tube feeding at a rate of 40 ml/hr. This positioning was contrary to the facility's policy, which requires the head of the bed to be elevated between 45 to 90 degrees during feeding. Resident 107, who was admitted with diagnoses including peptic ulcer, severe intellectual disabilities, and oropharyngeal phase dysphagia, had a care plan that emphasized the importance of preventing aspiration. Despite this, the observation revealed a lapse in following the care plan's directive to monitor and report signs of aspiration. During an interview, an LPN acknowledged the incorrect positioning and adjusted the bed accordingly. The Director of Nursing later confirmed that staff are expected to elevate the head of the bed to the appropriate angle after care is completed.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. The resident had a physician's order for Albuterol Sulfate Solution Nebulizer and oxygen therapy. However, the facility did not have a policy for the cleaning and storage of nebulizer machines. During observations, the nebulizer machine was found in the resident's room with the oxygen mask propped against it, not bagged, and with clear liquid in the medication chamber. The oxygen concentrator was set at 2.5 liters per minute, contrary to the resident's statement of being on 2 liters of oxygen. Interviews with the Director of Nursing (DON) revealed that the nebulizer mask and medication chamber should be cleaned with water, air-dried, and stored in a zip lock bag. However, this procedure was not followed, as evidenced by the observations of the nebulizer equipment not being properly cleaned or stored. The lack of a facility policy and the improper handling of the nebulizer equipment led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement an appropriate fall intervention for a resident, leading to multiple incidents where the resident fell from their wheelchair. The resident, who had a medical history of gait and mobility abnormalities, dementia, osteoporosis, osteoarthritis, and muscle weakness, was admitted to the facility in May 2021. The resident's care plan identified a potential for falls due to limited mobility and other health issues, yet the interventions in place were insufficient to prevent the wheelchair from rolling away during transfers. The resident experienced several falls, including incidents where the wheelchair rolled from underneath them, resulting in minor injuries such as lacerations and bruising. Despite these incidents, the facility did not implement effective interventions to prevent the wheelchair from rolling. The facility's accident reports noted that interventions like using a nonskid pad or locking the wheelchair brakes were considered but not implemented. The resident's cognitive impairment further complicated the situation, as they were unable to remember to lock the wheelchair independently. Interviews with facility staff, including the Director of Nursing and the Physical Therapy Assistant, revealed that the facility did not have a consistent approach to addressing the resident's fall risk. The staff acknowledged the need for better interventions but did not have a system in place to ensure that effective measures were implemented promptly. The lack of immediate and appropriate interventions contributed to the ongoing risk of falls for the resident.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Cheraw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehab Center Of Cheraw | 1.1 mi | — | 8 | 0 |
| Bennettsville Health And Rehabilitation Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-rockingham | 19.1 mi | ★★★★★ | 1 | 0 |
| Richmond Pines Healthcare And Rehabilitation Cente | 19.2 mi | ★★★★★ | 5 | 0 |
| Wadesboro Health & Rehab Center | 19.3 mi | ★★★★★ | 0 | 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.