Rehab Center of Cheraw

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on review of the facility's policy entitled, Activity Policies and Procedures, record review, observations, and interviews, the facility failed to provide an ongoing program of activities to meet the needs and interest of each resident for one (1) of three (3) residents reviewed for activities (Resident (R)18).Findings include:Review of the facility's policy entitled, Activity Policies and Procedures, stated, POLICY: Based on a comprehensive assessment, individualized care plan and the preferences of each resident, the Activity/Recreation Director and staff will provide an ongoing Activity/Recreation program to support resident personal choice of activities, facility-sponsored group, one to one activities, and independent activities designed to meet the interests of and support the physical, intellectual, psychosocial, emotional and spiritual well-being of each resident, encouraging both independence and community interaction.Purpose: To implement an…

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 record review, Payroll-Based Journal (PBJ) staffing data, Resident Council interview responses, and a staff interview, the facility failed to ensure sufficient nursing staff to meet the needs of residents as evidenced by low weekend staffing and missing Registered Nurse (RN) hours, affecting residents' timely access to care on a facility-wide basis. Findings include:Record review of the Payroll-Based Journal (PBJ) staffing data for Fiscal Year (FY) 2025, Quarter Four (Q4) identified excessively low weekend staffing levels. The submitted PBJ data for Q4 is consistent with undocumented licensed Registered Nurse (RN) hours and required shifts for facilities with greater than 60 residents.Record review of Resident Council Meeting Minutes dated for 07/22/2025 identify an unresolved Nurse call out issue and reference late medication administration and unspecified disturbances.Record review of the Daily Licensed and Unlicensed Direct Care Staff hours between November 11, 2025 and December 30, 2025 reveal ten (10) instances of missing RN coverage and only document Licensed…

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 observations, resident and staff interviews, record reviews and the facility's policy entitled, Nursing Policies and Procedures, the facility failed to provide Activities of Daily Living, (ADLs) for Resident (R)18 related to hair and dental care, and for R90 related to nail care, for two (2) of five (5) residents reviewed for activities. Findings include: Review of the facility policy titled, Staff Education /Orientation Polices and Procedures, revised 1/12/2024, states performance criteria as follows: 5. Fills basin with warm water 6. Soak nails 7. Clean under nails with orange stick. Review of R90's face sheet revealed R90 was admitted to the facility on [DATE] with diagnoses including but not limited to contracture of the left wrist, other pericardial effusion (non-inflammatory), other abnormal involuntary movements, other lack of coordination, muscle weakness (generalized), and flaccid hemiplegia affecting the left nondominant side. Review of the Physician Orders written on 08/11/25 revealed…

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 record review, interview, and observation, the facility failed to ensure Resident (R)32's wound dressing was changed daily in accordance with physician orders. The resident's bandage had not been changed for five (5) days and was observed to be visibly soiled with dried blood. Findings include:R32 was admitted to the facility on [DATE], with diagnoses including, but not limited to, cerebral palsy, functional quadriplegia, psychosis, mild intellectual disability, and left hand contracture.R32 was assessed as having a 0.5 cm x 0.5 cm wound on the right upper arm.Review of Physician Orders revealed orders including, but not limited to: Wound R[right] Arm Upper: Clean the wound with wound cleanser or normal saline, pat dry, apply honey, and cover with a bordered gauze dressing (BGD) to be changed daily and as needed (PRN).Review of R32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2025 revealed R32 had a Brief Interview of Mental Status (BIMS) score of 2 out of 15,…

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 the facility policy, medical records, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent for 2 out of 25 opportunities for error. The med error rate was 8 percent. Findings include: Review of the facility policy titled, Medication Management Program, under Policy states,The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements.3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Review of the facility policy titled, Staff Education/Orientation Policies and Procedures, under the competency, Medication Administration - Insulin Pen, states under the Performance Criteria, Priming the Pen, 1. Remove the outer needle cap and dial 2 units. 2. Points the pen up and presses the…

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 the facility policy, observation and interview, the facility failed to ensure a significant medication error did not occur for Resident (R)50, when Licensed Practical Nurse (LPN)1 failed to correctly prime an insulin pen before administering a dose of insulin for 1 of 1 residents observed, receiving insulin via a pen during med pass. Findings include: Review of the facility policy titled, Staff Education/Orientation Policies and Procedures, under the competency, Medication Administration - Insulin Pen, states under the Performance Criteria, Priming the Pen, 1. Remove the outer needle cap and dial 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop or stream of insulin appears at the needle tip. During a observation on 01/12/2026 at 11:25 AM, LPN1 placed a needle on a Degludec Insulin Pen, then held the pen in the downward position toward the trash can and pushed the dose button expelling the 2 units used to prime the pen in the trash can. LPN1 confirmed that he had held the insulin pen…

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 record review, observation, and staff interviews, the facility failed to ensure medications were properly stored in one (1) of two (2) medication storage rooms at safe and appropriate temperatures in accordance with facility policy and manufacturer recommendations.Findings include:Review of procedure number 10.A.1 of the facility policy titled Pharmacy Services Policies and Procedures, last revised on 04/01/2022, revealed that facility staff are required to monitor and record refrigerator and freezer temperatures twice daily, with medication refrigerator temperatures maintained between 36-46 F (2-8 C). On 01/13/2026 at approximately 09:15 AM, review of medication storage areas was conducted. The facility was observed to have one medication storage room and two medication carts each located on the North and South wings. Review of the South Med Room refrigerator temperature logs revealed multiple documented dates with temperatures outside of the acceptable range.On 01/13/2026 at approximately 01:20 PM, the Mobile Director of Nursing (DON) was interviewed regarding the…

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 the facility's policy, record review, pharmacy delivery manifests, and interviews, the facility failed to ensure medications were available and administered as ordered, for 1 of 1 resident (Residents (R)6), reviewed for pharmacy services. Specifically, R6 missed six scheduled doses of a controlled pain medication (Oxycodone), over a three-day period. Finding Include: Review of the facility policy titled Medication Management Program last revised 01/15/25 revealed, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .Administering the Medication Pass . 15. If a medication is unavailable, contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery. Review of R6's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: pain, spondylosis…

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, and policy review, the facility failed to maintain infection prevention and control practices designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was evidenced by medication administration observations of Resident (R)1 and R18. The findings include: Review of the facility policy titled, Hand Hygiene/Handwashing dated 5/15/23 documented, Procedures: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .After: .B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids, blood or wounds .J. Contact with environmental surfaces in the immediate vicinity of patients/residents. Review of the facility policy titled, Blood Glucose Monitoring dated 5/5/23 documented, .If the manufacturer doesn't specify how the device should be cleaned and disinfected, then it shouldn't be shared. Review…

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 record review, interviews, and review of the facility policy, the facility failed to ensure 1 out of 3 residents was free from significant medication errors for 1 out of 30 days for the month April 2024. Resident (R)1 received Lyrica; 1 capsule by mouth, 1 time a day and Norco 325 milligrams (mg); 1 tablet, 2 times a day. R1's Controlled Drug Receipt/Record/Disposition Form revealed medication was pulled and reported not administered, which heightened the likelihood of a decline in medical conditions. Findings include: Review of facility's policy titled, Medication Management Program with a revision date of 05/05/23 documented under Administering Medication Pass (8) The authorized staff member or licensed nurse must identify the resident before administering any medication. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to;anxiety, dementia, chronic obstruction pulmonary disease and heart failure. Review of R1's Quarterly Minimum…

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 reviews and interviews, the facility failed to thoroughly investigate an elopement for 1 of 1 residents reviewed for elopement. Specifically, Resident (R)1 successfully eloped from the facility and was found down the street from the facility. Finding include: Review of the facility policy titled, Elopement with a revision date of 11/01/17, documented, Policy: . A prompt investigation and search will be conducted in a patient/resident is considered missing . Procedures: 11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. Document Requirements: Incident Report, Investigative Report, Nursing notes should reflect an accurate and detailed account of situation and outcome, Social Services notes need to address emotional assessment and interventions. Missing Patient/Resident Profile and Notification Record. Review of R1's Electronic Medical Record (EMR) revealed, R1 was admitted to the facility on [DATE]…

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.