Rehab Center Of Cheraw

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities to meet the needs and interests of one resident, R18, who was reviewed for activities. The facility policy stated that activities should be based on a comprehensive assessment, individualized care plan, and resident preferences, with ongoing group, one-to-one, and independent activities designed to meet physical, intellectual, psychosocial, emotional, and spiritual well-being. R18 was admitted with diagnoses including displaced intertrochanteric fracture of the right femur, arthritis of the right hip, muscle weakness, depression, anxiety disorder, and schizoaffective disorder. The quarterly MDS showed a BIMS score indicating moderate cognitive impairment, and that the resident required dependent assistance with bathing. During observations, R18 was found in bed in her room with no staff present and no books or other reading materials observed. On another observation, she was again in bed alone with no activities or reading materials present. R18 stated she did not participate in one-on-one or group activities, wanted to get out of bed and participate, but staff did not come to assist her. She also stated the facility had not provided reading materials or other one-on-one activities. She reported staff did not get her out of bed the previous day and that she did not attend in-room or group activities because no staff notified her of scheduled activities. The ADON stated it was her expectation that activities staff coordinate with nursing staff and CNAs so residents who want to attend group activities can do so, while a CNA stated she did not remember asking R18 if she wanted to get out of bed or participate. The Activities Assistant later stated that her prior statement that R18 had been invited to group activities was not supported by the activity log.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide enough nursing staff each day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. Review of Payroll-Based Journal staffing data for FY 2025 Q4 identified excessively low weekend staffing levels, and the submitted data reflected undocumented RN hours and required shifts for facilities with more than 60 residents. Review of the Daily Licensed and Unlicensed Direct Care Staff hours from November 11, 2025 through December 30, 2025 showed ten instances of missing RN coverage, with only LPN and CNA hours documented. Resident Council Meeting Minutes dated 07/22/2025 noted an unresolved nurse call-out issue and referenced late medication administration and unspecified disturbances. During a Resident Council meeting on 01/13/2026 with eleven residents present, all residents reported concerns about delays in assistance and staff response to call lights. When interviewed on 01/14/2026, the Mobile Administrator stated the missing RN hours were covered by an MDS Nurse functioning as a Unit Charge Nurse, but there was no documentation showing the MDS Nurse was working in the facility RN role during that time.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide ADL assistance for two residents. For one resident with diagnoses including contractures of the hands, generalized muscle weakness, and flaccid hemiplegia, staff did not provide adequate nail care. The resident had a physician order for daily nail checks, and the care plan noted a preference for long fingernails and refusal of staff nail cutting. During multiple observations, the resident was seen with long fingernails and visible brownish-black debris under the nails of both contracted hands. Staff interviews showed that a CNA provided hand washing during ADLs but did not perform nail care, while an LPN stated nails should be checked and cleaned during ADLs. The DON stated nail cleaning under the nails should occur daily when the resident is bathed. For the second resident, who had diagnoses including a healed right femur fracture, arthritis, muscle weakness, depression, anxiety disorder, and schizoaffective disorder, staff did not provide consistent hair and oral care. The resident had moderate cognitive impairment, required dependent assistance with bathing, and preferred bed baths. During observations, the resident’s hair appeared greasy and unkempt, and the teeth had visible plaque buildup. The resident stated she did not remember the last time her hair was washed, had requested hair shampooing on numerous occasions without it being done, and did not get her teeth brushed daily as she wanted. Staff interviews confirmed the missed care. The resident stated she had not received a bed bath, hair shampooing, or tooth brushing as expected. The ADON stated staff should offer residents the opportunity to brush their teeth twice daily and that hair washing should be included in bed baths. A CNA assigned to the resident stated she provided a bed bath but did not ask whether the resident wanted her teeth brushed, even though that was part of ADL care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident 32’s wound dressing was changed daily in accordance with physician orders. Resident 32 was admitted with diagnoses including cerebral palsy, functional quadriplegia, psychosis, mild intellectual disability, and left hand contracture, and was assessed as having a 0.5 cm x 0.5 cm wound on the right upper arm. The physician order directed staff to clean the wound with wound cleanser or normal saline, pat dry, apply honey, and cover with a bordered gauze dressing to be changed daily and as needed. An observation of Resident 32 on 01/11/2026 at 11:05 AM showed an unclean dressing on the right upper arm dated 01/06/2026, indicating it had not been changed for five days. The bandage was visibly soiled with excessive dried blood. During interview, an LPN confirmed the dressing should have been changed daily and as needed per the physician order. The DON stated the facility has a wound care nurse who works Monday through Friday, and when that nurse is not present, the assigned nurse is responsible for wound care; the DON also confirmed dressings are dated so staff can identify when they were last changed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a medication administration error rate of less than 5 percent, with 2 errors identified out of 25 opportunities for error, resulting in an 8 percent med error rate. Facility policy required licensed nurses to evaluate, assess, monitor, document, and report the effectiveness of the medication regimen, and the staff education policy for insulin pen administration required priming the pen by pointing it up and expelling 2 units until a drop or stream of insulin appeared at the needle tip. During a med pass observation, an LPN removed Miralax 17 grams for a resident and placed it in a plastic cup, then filled the cup with water that did not contain the ordered 6 to 8 ounces. The LPN administered the Miralax with the smaller amount of water, and later confirmed the amount was not the ordered volume. In a separate observation, the same LPN attached a needle to a Degludec insulin pen and primed it while holding the pen downward toward the trash can, expelling the 2 units in the wrong position. The LPN confirmed the pen had been held downward instead of upward and could not confirm that the resident received the correct ordered dose of 15 units subcutaneously twice a day.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A significant medication error occurred for Resident R50 when LPN1 failed to correctly prime a Degludec insulin pen before administering insulin. Facility policy for insulin pen administration required the pen to be primed by removing the outer needle cap, dialing 2 units, and holding the pen up so insulin could be expelled until a drop or stream appeared at the needle tip. During observation on 01/12/2026 at 11:25 AM, LPN1 attached a needle to the insulin pen and held it downward toward the trash can while pressing the dose button, expelling the 2 units used to prime the pen into the trash can instead of priming it in the correct upward position. LPN1 confirmed that the pen had been held downward to prime it and not in the correct position. Review of R50's physician orders showed Degludec Insulin Pen, 15 units subcutaneously twice a day, and LPN1 could not confirm that R50 received the correct ordered amount of insulin.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications were properly stored in one of two medication storage rooms at safe and appropriate temperatures in accordance with facility policy and manufacturer recommendations. Facility policy required staff to monitor and record refrigerator and freezer temperatures twice daily, with medication refrigerator temperatures maintained between 36-46 F (2-8 C). During observation of the medication storage areas, the facility had one medication storage room and two medication carts located on the North and South wings, and review of the South Med Room refrigerator temperature logs showed multiple documented dates with temperatures outside the acceptable range. During interview, the Mobile DON was unable to explain how medications stored in the refrigerator were managed during periods of out-of-range temperatures and referred the surveyor to other staff members, who stated they would need to revisit the issue. The Regional EVS staff member later stated that the refrigerator thermometer differed from an infrared thermometer by about five degrees, with the infrared thermometer reading 35 F and the refrigerator thermometer reading 30 F. Although the acceptable refrigerator temperature range was discussed and the old thermometer was said to be replaced, no explanation was provided for how the out-of-range temperatures were resolved to ensure medication safety.

Penalty

Inspection fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to ensure that a resident with dysphagia and documented swallowing difficulties received a therapeutic diet consistent with the recommendations of the Speech Language Pathologist (SLP). The resident, who had diagnoses including dementia, dysphagia, and aphasia, was admitted on a regular diet with nectar thick liquids. Multiple SLP evaluations and weekly treatment plans recommended a mechanical soft diet and nectar thick liquids due to poor swallow safety, moderate confusion, and observed difficulties such as holding food in the mouth, coughing or choking during meals, and spitting or spilling food. Despite these recommendations, the resident continued to receive regular textured food. The resident's care plan did not include interventions related to a therapeutic diet, and the diet order in the electronic medical record did not reflect the SLP's recommendations for a mechanical soft diet. Staff interviews revealed a lack of awareness regarding any changes to the resident's diet, with nursing and dietary staff indicating that they were not informed of the SLP's recommendations. The SLP stated that diet communication slips were provided to both dietary and nursing departments, but the new diet recommendation was not effectively communicated or implemented. On the day of the incident, the resident was served a meal that included a hot dog, which is specifically listed as a food to avoid for individuals on a mechanical soft diet. The resident was later found unresponsive and without a pulse after eating, with staff and EMS removing pieces of hot dog from her airway. The resident suffered asphyxiation and expired in the facility. The deficiency was cited under 42 CFR 483.25 for failure to provide adequate nutrition and hydration consistent with the resident's clinical needs.

Removal Plan

• Resident is no longer in the facility.
• Resident was picked up on speech caseload with a goal of consuming regular diet and thin liquids. Resident was discharged from speech with recommendations for mechanically altered diet and thin liquids.
• New diet recommendation not communicated effectively by speech therapist to dietary or nursing departments. Investigation initiated and contracted therapy provider was notified. SLP will be suspended pending investigation. Regional therapist in house for an additional audit of residents on current speech caseload.
• An audit of current resident's diet as well as most current speech recommendations will be completed by Interdisciplinary Team to identify any discrepancies. Discrepancies identified were corrected with recommended speech diets, provider notified, and care plans updated.
• Meal Tracker will also be audited to ensure ordered diets match the tray ticket. Discrepancies identified were corrected.
• Licensed nurses and therapy department were re-educated regarding the expectation that any changes to diet are communicated within the IDT team via diet communication slip. SLP to complete diet communication slip, keep a copy, and give a copy to DOR, CDM, and Nurse Manager.
• Dietary Communication Slips will be reviewed in clinical morning meeting Monday-Friday.
• Administrator/designee will review 3 residents per week, according to MDS assessment per calendar, to validate ordered diet matches most current speech recommendation.
• Facility Administrator/designee will be responsible for the overall implementation and validation of this plan.
• Results of these reviews will be presented to the Quality Assurance Performance Improvement committee for review and recommendations. Any concerns will be addressed at time.
• An Ad Hoc QAPI will be held.
• Medical Director was notified of the incident and plan for improvement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper infection prevention and control practices during medication administration for two residents. During an observation, a registered nurse (RN) placed medical supplies, including gauze, an open alcohol swab, a glucometer, and gloves, on surfaces without a barrier underneath. The RN used the same alcohol swab for multiple attempts to collect blood samples from the residents' fingers and did not clean or disinfect the glucometer between uses. Additionally, the RN handled the restroom door with gloved hands before administering insulin injections, which further compromised infection control protocols. The residents involved had significant medical histories, including Type Two Diabetes Mellitus, with one resident also having conditions such as diabetic neuropathy and acute osteomyelitis. The RN acknowledged understanding the importance of infection control but cited the facility layout as a challenge, describing the infection control measures as "nit-picky." Interviews with the unit nurse manager and the Director of Nursing confirmed that the RN was aware of the proper procedures but failed to adhere to them, leading to the observed deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the incident involving a resident who did not receive their prescribed medications on a specific day. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was prescribed Lyrica and Norco for muscle weakness and pain, respectively. However, the Controlled Drug Receipt/Record/Disposition Form indicated that the medications were pulled but not administered, which was confirmed by the resident who recalled not receiving the medications. The error occurred when RN1, who was new to the hall and working with an orientee, mistakenly believed the resident was not in their room due to a dialysis appointment. RN1 admitted to pulling the narcotic medications but not administering them, and claimed to have disposed of them with the orientee as a witness, although this was not documented on the narcotic sheet. The Director of Nursing confirmed that RN1 admitted to not administering the medications, and the facility's policy requires two signatures for medication disposal, which was not followed in this case.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that foods stored in the refrigerator and the main kitchen preparatory area were properly labeled, dated, and free from expiration. During an inspection, surveyors observed several instances of improperly stored food, including bags of lettuce with no open or use-by dates, and lettuce that was brown with pink build-up. Additionally, a crate of lettuce was found with black and brown spots, and a half head of lettuce wrapped in saran wrap was observed with a brown/pink substance, all without labels or dates. A metal pan labeled 'Stewed [NAME]' was found with a use-by date, but the condition of the food was not specified. In the main kitchen preparatory area, a cardboard box containing Idaho potatoes was found with 8 out of approximately 20 potatoes being rotten, exhibiting black, grey, and green spots, and were soft to the touch. Interviews with the Dietary Manager (DM) and the Director of Nursing (DON) revealed that the expectation was for kitchen staff to monitor and dispose of expired foods daily, using the first in, first out (FIFO) method. However, this practice was not being consistently followed, leading to the presence of expired and improperly stored food items in the facility's kitchen.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of incorrect medication administration and documentation. One incident involved a Licensed Practical Nurse (LPN) administering insulin to a resident using an insulin pen. The LPN did not remove the needle cover during the priming process, which resulted in uncertainty about whether the insulin was properly expelled. This led to the resident receiving insulin from two pens without confirmation of proper priming, contrary to the facility's policy on insulin administration. Another deficiency was identified with a resident who did not receive several prescribed medications, including antipsychotic and antidepressant drugs, during a night shift. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained blanks for the administration of these medications, and the Director of Nursing (DON) could not provide a reason for the missing documentation. This lack of documentation and medication administration was not in line with the facility's policy, which requires documentation and notification if medications are not given. Additionally, a resident with a history of hypertension and other chronic conditions did not receive their scheduled blood pressure medication, metoprolol tartrate, on two occasions. The resident reported high blood pressure readings and expressed concern about not receiving the medication. The MAR showed blanks for the scheduled doses, and the DON confirmed that physician orders were not followed. The facility's reliance on agency nurses was noted as a challenge in maintaining consistent medication administration and documentation practices.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement the Comprehensive Plan of Care for a resident, identified as R24, who experienced significant weight loss and lacked engagement in activities of interest. R24 was admitted with diagnoses including depression, anxiety, bipolar disorder, and schizophrenia, and was noted to have severe cognitive impairment. The resident's weight decreased from 243.8 pounds on admission to 215.0 pounds over a period of approximately two months, indicating a total weight loss of 28.8 pounds. The Comprehensive Plan of Care included interventions to maintain nutritional status, such as encouraging dining in the dining room, honoring food preferences, monitoring intake, and offering snacks. However, the Registered Dietician (RD) was not informed of the weight loss, and no specific interventions were documented to address the significant weight loss until a dietary supplement was ordered on the day of the interview. Additionally, the facility did not implement the planned one-to-one activities for R24, who was non-verbal and required individualized attention to meet her physical, emotional, and intellectual needs. The Comprehensive Plan of Care outlined various one-to-one activities, including pet therapy, religious visits, music hour, and socialization, with a start date of March 18, 2024. However, the activity attendance sheets revealed no documentation of these activities being provided, and the Activity Director confirmed that no one-to-one activities were offered or documented for February 2024. This lack of implementation of the care plan contributed to the deficiency in providing adequate care for R24.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor behaviors and medication side effects for two residents, R60 and R20, who were reviewed for unnecessary medications. R60, who was cognitively intact, had a care plan that included monitoring for potential discomfort and adverse effects related to the use of antipsychotic and antidepressant medications. However, there was a lack of documentation for behavior monitoring related to antidepressant use and side effect monitoring for antipsychotic and hypnotic use on specific dates. The Director of Nursing (DON) acknowledged the expectation for physician orders to be followed and documentation to be completed by the end of each shift, but noted challenges due to the use of agency nurses. R20, who had multiple diagnoses including schizoaffective disorder and dementia, also had a care plan indicating a potential for adverse effects from antipsychotic and antidepressant medications. Despite physician orders for behavior and side effect monitoring, there were several instances where R20 did not receive the required monitoring, as indicated by blanks in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The DON confirmed the presence of these blanks but was unsure of the reasons behind them. The facility's policies on medication management emphasize the importance of monitoring each resident's medication regimen to maintain their highest practicable wellbeing. However, the lack of documentation and monitoring for R60 and R20 suggests a failure to adhere to these policies, leading to the identified deficiencies. The report highlights the facility's struggle with ensuring compliance, particularly with the involvement of agency nurses, which may contribute to the inconsistencies in documentation and monitoring.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care and services to prevent significant weight loss for two residents, R24 and R91, as per the facility's policy titled 'Weighing the Resident.' The policy mandates that weights be recorded and monitored monthly, and any significant weight changes should prompt reweighing, notification of relevant parties, and intervention by the dietitian. However, the facility did not adhere to these procedures, resulting in significant weight loss for both residents without timely intervention. Resident R24, admitted with severe cognitive impairment and multiple diagnoses, experienced a weight loss of 28.8 pounds over a period of approximately two months. Despite the policy's requirement to notify the physician and dietitian of significant weight changes, the Registered Dietician (RD) was not informed and only became aware of the weight loss by independently checking the records. The RD noted that a dietary supplement was recommended but not ordered, and there was no documentation of snacks being offered or consumed, as stated by the Director of Nursing (DON). Resident R91, also with severe cognitive deficits and multiple health issues, lost 23.62 pounds over six months. The RD acknowledged the weight loss and noted poor intake despite the provision of supplements like Ensure and sugar-free ice cream. However, no additional interventions were made after observing continued weight loss in March. The DON stated that staff are expected to notify the physician and RD of weight loss, but this did not occur, and the resident's weight loss continued without adequate intervention.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that each Certified Nursing Assistant (CNA) employed received the required minimum of 12 hours of in-service education based on their individual performance reviews. This deficiency was identified during a review of the facility's policy, staffing documentation, and interviews. The facility's policy on staff education and orientation outlines that all new employees receive a general orientation on their first day, followed by department-specific orientation starting on the second day. Additionally, the policy states that employees must complete annual competency evaluations and educational requirements according to state regulations. However, a review conducted on April 23, 2024, revealed that less than the required 12 hours of training had been provided to CNAs from their date of hire. The review found that 3 out of 5 CNAs did not receive training in critical areas such as resident's rights, abuse, neglect, exploitation, and dementia. Specifically, CNAs hired on May 23, 2019, February 1, 2023, and March 10, 2023, lacked documentation verifying the required training. During an interview, the Director of Nursing (DON) confirmed that the staff had not met their required training hours, despite the facility's process of annual training and skills checks to ensure competency. The DON stated that staff are evaluated by the staff development coordinator, but acknowledged the deficiency in meeting the required training hours.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication administration error rate of less than 5 percent, with the error rate reaching 10.71 percent. This deficiency was identified through staff education and orientation reviews, record reviews, observations, and interviews. Specifically, the facility's staff did not adhere to the correct procedures for administering insulin via an insulin pen, as outlined in the facility's policies. During an observation, a nurse administered insulin without properly priming the pen, as she held the pen horizontally and expelled the priming dose without removing the needle cover, failing to confirm insulin expulsion. Additionally, the facility did not ensure timely medication administration for a resident, identified as R5, whose medications were administered and charted late for 22 out of 31 days in March 2024. The resident had multiple diagnoses, including chronic kidney disease, diabetes, and heart failure, and was cognitively intact with a BIMS score of 15 out of 15. The resident's medication administration record showed several instances of late charting for various medications, including those for chronic obstructive pulmonary disease, heart failure, and renal dialysis, among others. Interviews with the Director of Nursing and the Administrator revealed that the facility's expectation was for medications to be administered within a one-hour window before or after the scheduled time and documented immediately. However, the observations and record reviews indicated that these expectations were not consistently met, contributing to the high medication error rate and late administration of medications for the resident.

Penalty

Inspection fine: $8,697

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure expired medications were removed from and not stored with medications in use for residents in two of four medication carts. During an observation of the North Hall Medication Cart B, it was found that Famotidine 40 milligrams, manufactured by Teva USA, had expired on 02/15/24, and a Lispro Kwikpen, manufactured by Lilly, was opened on 03/14/24 and expired on 04/11/24. Additionally, a Novolog Flex Pen was opened on 03/25/24 and expired on 04/22/24. These expired medications were confirmed by an LPN. In another observation of the South Hall Medication Cart A, a pen of Toujeo was found in use without an open date. This was confirmed by an LPN, who then removed the medication from the cart. The facility's policy on Medication Storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures for medication destruction.