Cheraw Healthcare: Wrong Medication Immediate Jeopardy - SC
The resident, identified in inspection records only as R1, received a single dose of hydralazine 40 mg, a single dose of hydralazine 100 mg, and a single dose of gabapentin 100 mg, all prescribed for her roommate. By the time emergency medical services arrived, R1's blood pressure was low and her mental status was described as "somewhat subdued." EMS administered Narcan and a liter of lactated Ringer's solution before transporting her. At the hospital, she received another milligram of Narcan.
The nurse, identified as RN1, explained what happened in an interview with inspectors on November 3. She had already pulled the roommate's medications and placed them in a cup. When she heard R1 yelling for help from the restroom, she carried the cup into the room, helped R1 up from the toilet, and gave her the medications. She realized her mistake afterward.
"She became diaphoretic and her heart rate decreased," RN1 told inspectors. "So, I notified my Unit Manager and she called the Nurse Practitioner and got an order to transport the resident to the ER."
What RN1 did not do was document R1's vital signs anywhere in the medical record.
The Director of Nursing told inspectors on November 6 that she could not find any record of vital signs being monitored after the error. She said she would have expected the nurse to document them so she could report to the physician.
The Unit Manager said she knew RN1 had been monitoring the vital signs. She described the conversation she had with RN1 after the nurse came to her: "I told her to call the physician and give him the information and go from there." She also confirmed the vital signs were not in the medical record. She said she would have expected them to be documented.
They were not. Nobody recorded them.
Federal inspectors cited the facility for Immediate Jeopardy, the most serious classification available under CMS, reserved for situations where a facility's failure has caused or is likely to cause serious injury or death to a resident.
The medication mix-up itself reflects a breakdown at the most basic level of nursing practice. Hydralazine is a blood pressure medication. Giving a resident who was not prescribed it a combined dose of 140 mg, while also administering gabapentin, a drug that affects the central nervous system, produced exactly the kind of crisis that medication verification procedures exist to prevent. R1's low blood pressure and altered mental status were consistent with the drugs she had received. The need for Narcan suggests the combination suppressed her respiratory or neurological function enough to require reversal.
The facility's Immediate Jeopardy removal plan, submitted to inspectors on November 6, described steps taken after the incident. Residents' names were placed outside their doors. Photographs were added to the electronic medical record. Identification bracelets were placed on all residents. An in-service on medication administration was completed. The Director of Nursing was to monitor medication administration competencies weekly for four weeks, then monthly for three months, then quarterly.
The plan also noted that R1 returned from the hospital on August 26 with no adverse effects.
That date, along with others in the removal plan, points to the incident having occurred in late August 2025, not in November. The November inspection appears to have been triggered by a complaint filed after the fact, with inspectors arriving to review what had already happened and what the facility had done about it.
What the facility had not done, in the weeks between the incident and the inspection, was ensure that nurses were verifying patient identity before administering medications, at least not in any way that inspectors found documented. The identification bracelets, the photographs in the electronic record, the names on the doors, all of that came after R1 had already been taken away in an ambulance.
R1 came back. The facility said she returned with no adverse effects. But she had been pulled off a toilet in distress, given another person's blood pressure and nerve medications, lost consciousness or something close to it, and needed a drug that reverses opioid and sedative overdose, twice, before anyone got the situation under control.
The cup of medications had been sitting in the hallway, already pulled, waiting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cheraw Healthcare from 2025-11-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
Cheraw Healthcare in Cheraw, SC was cited for immediate jeopardy violations during a health inspection on November 7, 2025.
At the hospital, she received another milligram of Narcan.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.