Chesterfield Convalescent Center

F-F692, constituting substandard quality of care.

Findings Include:

Review of facility policy titled Rehabilitation Services Policies and Procedures last revised [DATE REDACTED], revealed, Screens will be conducted on all new admissions/readmission. Screens are also conducted on a quarterly and annual basis unless indicated. A Speech Language Pathologist will screen all patients/residents in facility at least every six months to assist in the determination of patient/resident need for ongoing use of feeding tube and/or to provide services to attempt to restore, if possible, normal eating skills and/or identify and manage related complications of feeding tube use. Under circumstances whereby a screening process is insufficient to determine above an SLP, and the order of physician, may conduct a formal evaluation to accomplish same.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 5 425302 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425302 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rehab Center of Cheraw 1150 State Road Cheraw, SC 29520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Review of the undated facility policy titled Mechanical Soft revealed, The mechanical soft diet is used to optimize nutritional intake for individuals who have difficulty chewing or swallowing. Clients who exhibit Level of Harm - Immediate dental problems, missing teeth, no dentures, chewing or swallowing problems that may be diagnosed with jeopardy to resident health or oral pharyngeal dysphagia, and those with generalized weakness to help improve overall intake. Individuals safety with a wide variety of chewing and swallowing abilities as well as having a variance in alertness will benefit from this altered consistency diet. Foods to avoid: hot dogs; sausages (unless ground or finely chopped; Residents Affected - Few chunky nut butter; fish with bones.

Review of Resident R248's Face Sheet revealed Resident R248 was admitted to the facility on [DATE REDACTED], with diagnoses including but not limited to: Dementia, dysphagia and aphasia.

Review of Resident R248's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE REDACTED], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the interview was unable to be completed. Further review revealed, Resident R248 presented with the following signs and symptoms of

a swallowing disorder: Holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and a nutritional approach of a Mechanically Altered Diet while a resident. Resident R248 also required supervision or touching assistance when eating.

Review of Resident R248's Electronic Medical Records (EMR) revealed a diet order with a start date of [DATE REDACTED], revealed, House, Nectar. Special Instructions: Fortified Mashed Potatoes lunch & dinner.

Review of Resident R248's SLP Evaluation and Plan of Treatment dated [DATE REDACTED] and [DATE REDACTED], revealed Resident R248 was referred for services due to poor swallow safety and moderate confusion. Resident R248 had recommendations for Mechanical Soft textures and Nectar thick liquids.

Review of Resident R248's Weekly SLP Evaluation and Plan of Treatments dated [DATE REDACTED]/, [DATE REDACTED] and [DATE REDACTED] - [DATE REDACTED], revealed Resident R248 had recommendations for Mechanical Soft textures and Nectar thick liquids.

Review of the Week-at-a-Glance menu for [DATE REDACTED], revealed, Chili Dog with cheese, seasoned French fries, seasoned corn, sherbet and a beverage of choice.

Review of Resident R248's Care Plan did not revealed a Care Plan or interventions related to Resident R248's theraputic diet.

Review of Resident R248's Progress Note dated [DATE REDACTED], revealed, She has expressive aphasia and requires mech altered meals/liquids for aspiration precautions.

Review of Resident R248's Progress Note dated [DATE REDACTED], revealed, This nurse was notified by [CNA1] and [CNA3] that resident looked pale and asked me to assess resident. Resident was noted to be very pale with no respirations and no pulse. Resident was immediately lowered to the floor by staff from her wheelchair and

this nurse initiated CPR while [CNA3] called 911. RN (residents nurse) entered the day room and took over CPR as this nurse began to gather residents paperwork and notify [residents emergency contact]. notified residents other family including the residents father. EMS arrived and continued life saving interventions in facility and in the ambulance. Interventions were unsuccessful. notified administrator, notified on call MD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 425302 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425302 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rehab Center of Cheraw 1150 State Road Cheraw, SC 29520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Review of a South Carolina Pre-Hospital Care Report dated [DATE REDACTED], revealed the following: Incident Information: [Local] Emergency Medical Services (EMS) agency was dispatched to Rehab Center of Cheraw Level of Harm - Immediate at 5:33 PM for Unconscious/Fainting/Near-Fainting, patient evaluated, and care provided. Impression: jeopardy to resident health or Primary and secondary symptoms/impressions noted as cardiac arrest. Patient Care Report Narrative: A- safety [EMS1] dispatched for a female patient unconscious CPR in progress. Upon arrival on scene patient was found laying supine on the floor workers doing compressions. Facility stated that she was eatting [sic] and Residents Affected - Few they come to check on her and found her not breahting [sic] no pluse [sic] and began chest compression stated she might have choked on a hotdog that she was eatting [sic]. Patient treatment is as documented. IGEL (device for securing and maintaining a patient's airway) Put in place after removing hotdog pieces from airway. Cardiac Arrest: Yes, Prior to EMS Arrival, Etiology (Cause): Respiratory/Asphyxia (Oxygen deprivation)

Review of Resident R248's Emergency Department (ED) progress note dated [DATE REDACTED] at 6:16 PM, revealed, Per, EMS, presenting from [Facility] for cardiac arrest. Staff members reportedly had served [Resident R248] a dinner tray, and about 3 to 4 minutes when they return to her room, found her slumped over, unresponsive and pulseless. EMS had performed 30 minutes of cardiac resuscitation prehospital, 4 rounds of epinephrine and placed an I-gel. They noticed chunks of hotdog in her airway that was obstructing, and they removed some prior. Under the medical decision making section the following was also revealed: Patient was intubated by me as I suspected foreign body/aspiration. I was able to remove a chunk of a hot dog from her left cheek, otherwise I did not visualize any additional foreign body or food products within the airway/covering her cords.

Review of surveillance video footage provided by the facility, recorded on [DATE REDACTED] at 5:24 PM, Resident R248 can been seen in an empty day room, wheeling herself up to a table where she begins to eat her lunch. At approximately 5:31 PM, Resident R248 is noted to be slumped over the back of her wheelchair non- responsive. A facility staff member is then seen walking up to Resident R248, stands a few feet from her looks over then exits the room. At 5:32 PM, two additional staff members enter the day room and seen checking on the resident and places her on the floor. One minute later at 5:33 PM, CPR is begun and the video ends.

During an interview on [DATE REDACTED] at 11:02 AM, the Registered Dietitian (RD) stated, he visits the facility weekly.

He will ask the floor nurses if there have been any changes with residents, he needs to be aware of. The RD also reviews speech therapy notes and if they make any recommendations, they go with them and follow the recommendations. The RD also states when changes are made to diet orders the floor supervisor will place those in the resident's records. The RD was unable to recall what diet Resident R248 was on, or any recommendations made as he did not have the information available to review.

During an interview on [DATE REDACTED] at 12:03 PM, Licensed Practical Nurse (LPN)1 and Certified Nursing Assistant (CNA)1 stated, they are familiar with Resident R248 and her care. They stated on the day of the incident Resident R248 was in

the north day room eating when CNA1 noticed that she was looking pale and went to get the nurse. LPN1 and other staff members removed her from the chair down to the floor and started CPR. LPN1 did a clean sweep of her mouth and food was present such as bread and portions of a hot dog. LPN1 states that she was aware that she had diagnoses of dysphagia, but she wasn't aware of any changes with her diet, she just knows that she was working with ST. They stated, supervision or touch assistance with meals means the residents are in a group setting to be monitored more closely. LPN1 stated the ST makes the recommendations to the nursing department, unit manager then staff on the floor and it's also conveyed on

the meal ticket and Resident R248 was on a regular diet always.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 425302 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425302 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rehab Center of Cheraw 1150 State Road Cheraw, SC 29520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on [DATE REDACTED] at 12:21 PM, the Director of Nursing (DON) stated she isn't aware of any foods they are restricted on certain diets. When a resident is on a house diet that's like a regular diet with no Level of Harm - Immediate restrictions. When diet orders change, they follow diet communication slips. The nursing department and jeopardy to resident health or dietary manager can update diet orders. safety

During an interview on [DATE REDACTED] at 12:36 PM, CNA1 stated she is very familiar with Resident R248's care. She also Residents Affected - Few stated to her knowledge she isn't familiar with any residents who have difficulty swallowing, but normally sees residents who are packers, so their diet will change from regular to a mechanical or pureed diet. CNA1 states the ST communicates with the nurses and dietary staff when changes are needed via a communication slip and verbal order from ST.

During an interview on [DATE REDACTED] at 12:42 PM, the ST stated, Resident R248 was admitted on a regular diet, but he was trying her out on a mechanical soft diet. Resident R248 was not eating as much as she should with the regular diet. ST notes the texture for a resident with dysphagia depends on the resident, but the lowest level is pureed honey and highest is chopped easy chew. ST stated Resident R248 had mild difficulty with chewing, and he was seeing her 5x a week for 8 weeks. ST noted dysphagia affected Resident R248's eating and swallowing as she was chewing, spitting and spilling food out of her mouth. The ST further revealed when he completes a diet communication slip, he gives them both to dietary and the DON, and he also lets them know verbally. ST states if he turns in

a diet communication slip for lunch, it is to be in effect at dinner. ST confirmed the discharge summary from his assessment on [DATE REDACTED] had recommendations for soft mechanical textures and nectar thick liquids.

On [DATE REDACTED] at 5:45 PM the facility provided an acceptable IJ Removal Plan, identicating Past-Non- Compliance which included:

Resident identified has diagnosis of dysphagia. Resident is no longer in the facility.

Resident admitted on diet of regular textures and nectar thick liquids. Resident was picked up on speech caseload on [DATE REDACTED] and [DATE REDACTED] with a goal of consuming regular diet and th.in liquids. Resident was discharged from speech on [DATE REDACTED] with recommendations for mechanically altered diet and thin liquids.

New diet recommendation not communicated effectively by speech therapist to dietary or nursing departments. Investigation initiated and contracted therapy provider was notified. SLP will be suspended pending investigation. Regional therapist in house the week of [DATE REDACTED] thru [DATE REDACTED] for an additional audit of residents on current speech caseload.

An audit of current resident's diet as well as most current speech recommendations will be completed by Interdisciplinary Team to identify any discrepancies on [DATE REDACTED]. Discrepancies identified were corrected with recommended speech diets, provider notified, and care plans updated on [DATE REDACTED].

Meal Tracker will also be audited on [DATE REDACTED] to ensure ordered diets match the tray ticket. Discrepancies identified were corrected on [DATE REDACTED].

Licensed nurses and therapy department were re-educated starting on [DATE REDACTED]/2025, regarding the expectation that any changes to diet are communicated within the IDT team via diet communication slip. SLP to complete diet communication slip, keep a copy, and give a copy to DOR, CDM, and Nurse Manager.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 425302 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425302 B. Wing 05/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rehab Center of Cheraw 1150 State Road Cheraw, SC 29520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Dietary Communication Slips will be reviewed in clinical morning meeting Monday-Friday. Administrator/designee will review 3 residents per week, according to MDS assessment per calendar, to Level of Harm - Immediate validate ordered diet matches most current speech recommendation. jeopardy to resident health or safety Facility Administrator/designee will be responsible for the overall implementation and validation of this plan.

Residents Affected - Few Results of these reviews will be presented to the Quality Assurance Performance Improvement committee for review and recommendations for 3 months. Any concerns will be addresses at time.

An Ad Hoc QAPI will be held on [DATE REDACTED].

Medical Director was notified of the incident and plan for improvement on [DATE REDACTED].

Allegation of Compliance: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 425302