Cheraw Healthcare

Based on review of facility policy, record review, and interview, the facility failed to ensure and document annual performance evaluations were completed for 5 out of 5 Certified Nursing Assistants (CNAs) reviewed.Findings include:Review of the undated facility policy titled Skill Competency Evaluations, revealed, All Nurse's and CNA's will have competency evaluations performed during orientation, annually, and prn (as needed) by designated staff.Review of personnel records for 5 of 5 CNAs, revealed no documentation of an annual performance evaluation within the required timeframe.During an interview on 03/12/2026 at 11:21 AM, the Human Resource Director confirmed that annual competency evaluations have not been completed for the CNAs reviewed.During an interview on 03/12/2026 at 3:34 PM, the Administrator confirmed that although competency evaluations are required to be completed annually for nurses and CNAs, they have not been completed as required.

Based on review of facility policy, record review, observation and interview, the facility failed to ensure Resident (R)5 received the needed care and services related to activities of daily living. Specifically R5, was not provided routine hair and nail care, for 1 of 1 resident reviewed for activities of daily living.Findings include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting, with a revision date of March 2018, revealed as the policy statement, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy interpretation and implementation revealed, . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. 3. If…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for Resident (R)10, who has a diagnoses of Alzheimer's Dementia and is receiving 200 milligrams of Quetiapine at bedtime, for 1 of 5 residents reviewed for unnecessary medications. Findings include:Review of the undated facility policy titled, Unnecessary Medications, revealed, Purpose: To ensure residents are free from unnecessary medications and that all medications are prescribed and administered only when clinically indicated. The policy states, The facility will ensure that each resident's medication regimen is free from unnecessary medications. An unnecessary medication is defined as any medication used in excessive dose, excessive duration, without adequate monitoring, without adequate clinical indication, in the presence of adverse consequences, or without adequate attempts at dose reduction when indicated. 4. Residents receiving medications such as psychotropic medications will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observation and interview, the facility failed to ensure expired medications were removed from, and not in use with in-date medications for residents, in 1 of 4 medication carts.Review of the facility policy titled, Medication Labeling and Storage, states, . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. During an observation on 03/12/2026 at approximately 4:00 PM, of the South Hall medication cart #1, revealed one bottle of Aspirin, 325 milligram tablets, with Lot #921X06 was expired on 01/26/2026. During an interview on 03/12/2026 at 4:06 PM, Licensed Practical Nurse (LPN)1 confirmed the expired medication and removed the bottle of Aspirin from the medication cart.

Based on observation, interview, and record review, the facility failed to ensure temperatures were in range for safe food storage to prevent foodborne illness, in 1 of 2 nourishment room refrigerators.Findings include:Review of the undated facility policy titled, Policy: Resident Nourishment Refrigerator Temperature Monitoring, revealed, Purpose: To ensure all nourishment room refrigerators maintain safe temperature to prevent foodborne illness. Policy: All refrigerators used for resident nourishment storage will be maintained at 41 degrees F (5 degrees C) or below. Monitoring: Refrigerator temperature will be checked and documented daily by designated staff. Thermometers: Each refrigerator must contain a visible thermometer. Corrective Action: If temperature exceeds 41 degrees F, staff will recheck with 30 minutes and notify dietary or maintenance. Audits: Dietary manager or designee will conduct monthly audits to ensure compliance.During an observation on 03/12/26 at 8:40 AM, of the North Unit Hall-100 nourishment room refrigerator revealed the temperature gauge reading at 46…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility policy, and interviews, the facility failed to remove expired medications and biologicals from 2 of 2 medication storage rooms. Findings include: Review of the undated facility policy titled, Medication Storage In The Facility documented, Policy: Medications and biologicals are stored safely, securely and properly following manufacturers' recommendations or those of the supplier. During an observation and interview on 11/14/24 at 7:21 AM, the medication storage room on the South Unit revealed, One (1) BD Vacutainer Red Top with lot number 2258780 and expiration date 09/30/24. Licensed Practical Nurse (LPN)2 verified the item was expired and removed it from the medication room. During an observation and interview on 11/14/24 at 7:53 AM, the medication storage room on the North Unit revealed the following: -One (1) BD Vacutainer Gel and Lithium Heparin [NAME] Top with lot number 3290681 and expiration date 10/31/24. The Director of Nursing (DON) verified the item was expired and removed it from the medication storage room. -Two (2) boxes of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)11, R62, R73, R96, and R100, had the right to formulate accurate Advance Directives for 5 of 8 residents reviewed for Advance Directives. Findings include: Review of the undated facility policy titled, Advance Directives Policy documented, It is the desire of Cheraw Healthcare Inc. to inform each resident of his/her right to make an informed decision concerning their medical care including: Their right to refuse or accept medical and surgical treatment and the right to formulate advance directives . Each record will be marked to signify that Advance Directives have been made . Review of the undated facility policy titled, Procedures for Advance Directives (DNR, Living Wills, Durable/Health Care Power of Attorney) documented, Information with respect to Advance Directives (Living Wills and Health Care Power of Attorney) in the form of pamphlets Medical Treatment and Your Living Will and Your Right to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, observation, and interviews, the facility failed to complete a restraint assessment, for the use of trunk restraint on wheelchair, for Resident (R)47, for 3 of 4 residents reviewed for the use of restraints. Findings include: Review of the facility policy titled Restraint Assessment Policy with a revision date of [DATE], documents, 4. Orders must be obtained for any chemical or physical restraints. 5. Physical restraint assessment will be initiated to evaluate the appropriateness restraint use. Review of R47's Face Sheet revealed R47 was admitted to the facility with diagnoses including, but not limited to: Dementia, major depressive disorder, anxiety disorder, cerebrovascular disease, and overactive bladder. During an observation on [DATE] at 11:15 AM and on [DATE] at 10:06 AM, revealed R47 was sitting in her non mechanical wheelchair near the nurses station in North Unit, self-propelling with a lap n lock padded lap desk over her lap. R47's arms were crossed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)107 received proper positioning during tube feeding, which had the potential for aspiration for 1 of 1 resident reviewed. Findings include: Review of the facility policy titled Gastrostomy Tube Feeding (Bolus or Continuous Feeding) with a revision date of 10/10/19, documented, Purpose: 1. To feed the resident that has obstruction or disease of the esophagus or throat. 2. To feed the residents' that are unconscious or debilitated for long periods of time. 3. To reduce the danger of aspiration. 4. To provide adequate nourishment. Procedure: 6. Place resident in fowler's position [a semi-sitting position where a patient lies on their back with their head and upper body raised at an angle of 45° to 90°]. Review of R107's Face Sheet revealed R107 was admitted to the facility on [DATE], with diagnoses including but not limited to: peptic ulcer, gastroduodenitis, severe intellectual disabilities,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure Resident (R)33 nebulizer machine, oxygen mask and medication chamber were clean and/or bagged when not in use for 1 of 1 resident reviewed for respiratory care. Findings include: On 11/15/24 at 10:00 AM, a request was made to review the facility policy on maintenance and storage of equipment associated with respiratory therapy tasks particularly nebulizer machines. On 11/15/24 at 10:30 AM, the Director of Nursing (DON) stated that there was no policy for the cleaning and storage of a nebulizer machine. Review R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder. Review of R33's Physician Orders with a start date of 09/03/24 and a revision date of 09/20/24, revealed an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to implement an appropriate fall intervention to prevent the wheelchair from rolling for 1 (Resident (R)1) of 3 sampled residents reviewed for falls. Findings included: A facility policy titled, Fall Policy and Procedures, revised 07/04/2019, indicated, Objective: To assure as safe of an environment as possible for our residents. R1's Face Sheet revealed the facility admitted the resident on 05/19/2021. According to the Face Sheet, the resident had a medical history that included diagnoses of abnormalities with gait and mobility, dementia, osteoporosis, osteoarthritis, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed R1 did not have any behaviors during the assessment period. The MDS revealed the resident had no range-of-motion impairment to the upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.