Cheraw Healthcare
Cheraw Healthcare in Cheraw, SC — inspection on November 7, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
40 mg a single dose of hydralazine 100 mg and a single dose of gabapentin 100 mg.
Patient's blood pressure is low and mental status is somewhat subdued.
The patient received Narcan and 1 L of LR by EMS and 1 mg of Narcan by EMS.
During an interview on 11/03/25 at 10:03 AM, Registered Nurse (RN)1 stated it all started when R1 was in the restroom yelling for help. I had already pulled the medications for her roommate, and they were in a cup. I carried the cup of medication into the room and helped R1 get up from the toilet and then gave her the medications that were for her roommate.
When I realized it was a mistake, I started monitoring her.
She became diaphoretic and her heart rate decreased. So, I notified my Unit Manager and she called the Nurse Practitioner and got an order to transport the resident to the ER.
During an interview on 11/06/25 at 12:03 PM the DON stated she could not find in the medical record where the vital signs were monitored.
She stated that she would expect the nurse to monitor the vital signs so that she could report them to the physician.
During an interview on 11/06/25 at 12:10 PM, the Unit Manager stated that she knew the nurse was monitoring the vital signs. RN1 had come to her and told her she thought she gave the wrong medications to the resident and I told her to call the physician and give him the information and go from there.
The Unit Manager confirmed that the vital signs were not in the medical record and stated that she would expect the nurse to document them in the medical record. On 11/06/25 at 6:45 PM, the facility provided an acceptable IJ Removal Plan, which included the following:1. MD notified, and Resident was sent to the hospital on [DATE].
Returned to facility on 08/26/2025.
Resident returned with no adverse effects.2.
All residents were assessed by the Director of Nursing on 08/24/2025 with all residents without distress. VItal signs obtained and reviewed for abnormalities, none noted.
All residents assessed by Director of Staff Developement on 11/06/2025.
Roommate MAR (Medication Administration Record) reviewed for medication administration on 08/23/2025.
Resident received medications as ordered.3.
Resident's names placed outside doors and pictures placed on EMR on every resident.
Identification bracelets placed on all residents on 11/06/2025.
Inservice on Medication Administration, Medication Errors Policy & Procedures was completed on 08/25/2025.
Director of Staff Development and/or designee to provide skills competency to each nurse before next scheduled shift.4. DON to monitor medication administrations skills competencies weekly x4, monthly x3, then quarterly until compliance has been met.5.
Compliance date 08/24/2025.
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