Chesterfield Convalescent Center Fatal Choking SC
CHERAW, SC - A resident at Rehab Center of Cheraw died from choking on a hot dog after the facility failed to implement speech therapy recommendations for a mechanically altered diet, according to a state inspection report that found immediate jeopardy violations threatening resident health and safety.
Resident Served Wrong Food Despite Swallowing Disorder Diagnosis
The 62-year-old female resident, identified as R248 in the inspection report, had been diagnosed with dysphagia (difficulty swallowing), dementia, and aphasia when she was admitted to the facility. Despite multiple speech therapy evaluations recommending mechanical soft textures and nectar-thick liquids, she was served a regular dinner tray containing a chili dog with cheese on the day of her death.
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services. The final evaluation specifically recommended mechanical soft textures and nectar thick liquids due to documented swallowing difficulties. The facility's own policy clearly stated that hot dogs and sausages should be avoided unless ground or finely chopped for residents on mechanical soft diets.
Video surveillance footage reviewed by inspectors showed the resident eating alone in an empty day room at 5:24 PM. Seven minutes later, she was observed slumped over in her wheelchair. A staff member walked up to her, looked over, then left the room without providing assistance. Other staff members arrived one minute later and began CPR at 5:33 PM.
Critical Communication Breakdown Between Departments
The inspection revealed a systemic failure in communication between the speech therapy, nursing, and dietary departments. When interviewed, the Licensed Practical Nurse (LPN) on duty stated she "was aware that she had diagnoses of dysphagia, but she wasn't aware of any changes with her diet." The nurse believed the resident was always on a regular diet.
The speech therapist told inspectors he had completed diet communication slips with his recommendations and claimed he provided copies to both dietary and nursing departments. However, the resident's electronic medical records showed a diet order for "House, Nectar" with no mention of texture modifications, and her care plan contained no interventions related to her therapeutic diet requirements.
Dysphagia affects approximately 15% of elderly adults and significantly increases the risk of aspiration pneumonia and choking. When swallowing muscles weaken or coordination becomes impaired, food can enter the airway instead of the esophagus. Mechanical soft diets eliminate foods that require extensive chewing and exclude items like whole hot dogs that can obstruct airways. These dietary modifications are considered essential medical interventions for preventing life-threatening complications in dysphagic patients.
Emergency Response Reveals Extent of Obstruction
Emergency Medical Services documentation painted a grim picture of the incident's severity. The EMS report stated that responders "removed hotdog pieces from airway" after finding the resident in cardiac arrest. The emergency department physician who attempted resuscitation noted removing "a chunk of a hot dog from her left cheek" during intubation attempts.
The medical examiner's findings indicated the cause of cardiac arrest was "Respiratory/Asphyxia" due to airway obstruction. Despite 30 minutes of cardiac resuscitation and multiple rounds of epinephrine, medical personnel were unable to revive the resident.
Standard protocols for residents with dysphagia require not only appropriate food textures but also supervised eating environments. The resident's assessment indicated she required "supervision or touching assistance when eating," yet she was found eating alone in an empty day room. This represents a fundamental breach of basic safety protocols for vulnerable residents with known swallowing disorders.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Rehab Center of Cheraw in Cheraw, SC was cited for violations during a health inspection on May 6, 2025.
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services.
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.