Rehab Center of Cheraw

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to identify risks and hazards, failed to implement processes and failed to implement and monitor person-centered interventions for smokeless tobacco use for 3 of 3 Residents reviewed, (R)51, (R)71, and (R)77.

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure expired/outdated medications and biologicals were not stored with, and removed from storage away from other medications and biologicals in use for residents in 1 of 2 treatments carts and 1 of 4 medication carts. Findings Include: Review of the facility policy titled, Pharmacy Services Policies and Procedures, Section 8-Medication Storage, General Guidelines for Storage of Medication and Biologicals. last revised 04/01/22 revealed, Policy: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal Laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. [...]

Inspectors wroteNumber 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure that 1 of 3 residents reviewed for nutrition, Resident (R)248, received a therapeutic diet consistent with the resident's clinical condition and the recommendations of the Speech Language Pathologist (SLP). Specifically, the facility did not implement a recommended mechanical soft diet for R248, with dysphagia and documented swallowing difficulties. As a result, the resident continued to receive regular textured food resulting in the resident suffering from asphyxiation and expiring in the facility. On 05/04/25 at 3:26 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has cause or was likely to cause serious harm, serious impairment or death. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to properly supervise 1 of 1 resident to prevent an elopement. Specifically, Resident (R)1 had a successful elopement from the facility on 09/22/23. On 10/03/23 at 4:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 10/03/23 at 4:59 PM, the Administrator was notified that the failure to properly supervise a resident, resulting in the resident successfully eloping from the facility constituted Immediate Jeopardy (IJ) at F689. On 10/03/23 at 4:59 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 09/22/23. [...]

Inspectors wroteBased 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.