Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Jul 24, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to medication self-administration, medication storage, food safety, and infection control practices at The Gables of Pelham Skilled Nursing & Rehab.
Findings
The facility was found deficient in several areas including failure to assess a resident for safe self-administration of medication, failure to remove expired medications from storage, improper food storage and labeling practices, and lapses in infection prevention such as unsafe food handling and improper insulin administration technique.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to assess a resident for safe self-administration of medication; resident had unlabeled nasal sprays and no documented orders for self-administration. | Level of Harm - Minimal harm or potential for actual harm |
| Expired medications and biologicals were not removed from the medication storage refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Foods stored in kitchen and storage areas were not properly sealed, labeled, or dated; expired and spoiled food items were observed. | Level of Harm - Minimal harm or potential for actual harm |
| Unsafe food handling observed during meal preparation with metal can lids found in cooked dessert; improper infection control during insulin administration by failing to clean syringe hub before use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Expired Covid-19 Vaccine doses: 1
Expired Influenza Vaccine doses: 13
Number of kitchens inspected with food storage issues: 2
Number of refrigerators with food storage issues: 1
Number of freezers with food storage issues: 1
Number of dry food storage areas with food storage issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Failed to clean insulin syringe hub before insulin administration |
| Director of Nursing | Director of Nursing | Provided statements regarding medication self-administration policies and corrective actions |
| Dietary Manager | Dietary Manager | Provided statements regarding food storage and handling expectations and corrective actions |
| Administrator | Administrator | Oversight of kitchen and food safety practices |
| Dietary Aide | Dietary Aide | Observed handling food with metal can lids and provided statements about food labeling |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 10, 2025
Visit Reason
The inspection was conducted as an extended survey in conjunction with a complaint survey due to non-compliance related to chemical restraints, abuse prevention, and elopement risk at The Gables of Pelham Skilled Nursing & Rehab.
Findings
The facility failed to ensure Resident 1 was free from chemical restraints by administering Haloperidol Deaconate without an approved indication, failed to implement abuse prevention policies protecting Resident 4 from rough handling by a CNA, and failed to provide adequate supervision to prevent Resident 1 from eloping from the facility. Immediate Jeopardy was identified but subsequently removed after corrective actions.
Complaint Details
The complaint investigation was triggered by allegations of chemical restraint use without proper indication for Resident 1, abuse allegations involving rough handling of Resident 4 by a CNA, and an incident of Resident 1 eloping from the facility on 12/17/24. The facility was found non-compliant with federal regulations, resulting in Immediate Jeopardy declarations that were later removed after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 2
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to prevent use of unnecessary psychotropic medications or chemical restraints for Resident 1. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to implement abuse prevention policies to protect Resident 4 from abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision to prevent Resident 1 from eloping from the facility. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Medication doses given: 3
Medication active days: 17
Elopement incident date: Dec 17, 2024
Audit duration: 3
Inservice audit frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Reported exit seeking behavior of Resident 1 and involvement in medication administration and incident response. |
| DON | Director of Nursing | Monitored antipsychotic medication use, involved in abuse investigation and elopement incident response. |
| NP | Nurse Practitioner | Ordered Haloperidol injection for Resident 1 and clarified medication order errors. |
| Pharmacy Director | Pharmacy Director | Confirmed pharmacy transcription error related to Haloperidol Deaconate order. |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy, involved in abuse and elopement investigations and corrective action plans. |
| CNA1 | Certified Nursing Assistant | Alleged to have handled Resident 4 roughly during toileting. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 21, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for The Gables of Pelham Skilled Nursing & Rehab following a survey completed on 06/21/2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 30, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to timely notify a resident's representative after an accident, inadequate grooming care related to facial hair removal for residents, and improper disposal and maintenance of garbage dumpsters.
Findings
The facility failed to notify the resident representative in a timely manner after a resident's accident, failed to ensure appropriate grooming for residents dependent on staff for shaving, and failed to maintain dumpsters properly, resulting in potential health hazards due to pests and unsanitary conditions.
Complaint Details
The complaint investigation found that the facility did not notify the resident's family about an accident until more than 14 hours later, despite documentation indicating notification attempts. Family members expressed upset about the delay. The investigation also included review of grooming care and dumpster maintenance issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the resident representative in a timely manner for an accident with change of condition for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure 2 residents received appropriate grooming related to removal of facial hair. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure dumpsters were kept closed and the area around dumpsters was clean, posing potential health hazards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for falls/accidents: 6
Residents reviewed for ADL grooming: 3
Total sample of residents reviewed for ADL: 12
Dumpster missing door duration: 4
Dumpster grease fill level: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Documented incident report and progress notes related to resident accident and notification attempts |
| Social Service Director | SSD | Interviewed regarding family notification and resident representative's reaction |
| Director of Nurses | DON | Provided statements about resident grooming care expectations and awareness of issues |
| Maintenance Director | MD | Interviewed regarding dumpster conditions and maintenance responsibilities |
| Dietary Manager | DM | Interviewed regarding dumpster conditions and cleanliness |
| Executive Director | Provided statements on dumpster maintenance responsibility and observations |
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