Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gables Of Pelham Skilled Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that food items in storage areas were not consistently sealed, labeled, or dated, and expired or spoiled items were not discarded as required by facility policy. Staff interviews confirmed that labeling and discarding procedures were not always followed, resulting in multiple expired and improperly stored food items.
A resident was found to be self-administering two nasal sprays kept at the bedside without documented assessment or authorization from the interdisciplinary team, as required by facility policy. The resident, who was cognitively intact and had a history of orthostatic hypotension and syncope, used the sprays independently, but there was no physician order or care plan documentation permitting self-administration, and the medication labels were faded and unreadable.
Expired doses of Covid-19 and Influenza vaccines were found in the medication storage refrigerator, with staff unable to identify who was responsible for their removal or the correct disposal process. Although the DON indicated that nurses should check weekly and the pharmacist audits monthly, expired medications remained in storage, contrary to facility policy.
A dietary aide discovered metal can lids in two separate pans of apple crisp dessert during meal preparation, resulting in the disposal of the affected food. The cook confirmed the use of canned ingredients, and the administrator stated that food should be checked for foreign objects before serving. Additionally, an LPN failed to disinfect the top of an insulin syringe before administration, contrary to facility policy and manufacturer instructions, and acknowledged the omission during an interview.
A resident was improperly administered Haloperidol Deaconate (Haldol) for exit-seeking behavior without an approved indication or proper monitoring. The medication was given multiple times over 17 days due to a pharmacy transcription error and lack of communication among staff. The facility failed to follow its policy on chemical restraints, leading to a deficiency.
A resident with Alzheimer's disease and cognitive impairment eloped from a facility due to inadequate supervision. The resident was found outside an exit door in a wheelchair, attempting to pick berries. Despite being at significant risk for elopement, the facility did not use electronic monitoring devices and relied on a program to alert staff about high-risk residents, which was insufficient to prevent the incident.
A facility failed to implement its Abuse Prevention Program policy when a CNA accused of rough handling a resident was not immediately removed from the building. The resident, who was cognitively intact and had a history of a femur fracture, experienced pain and fear due to the CNA's actions. Despite the LPN's report to the DON, the CNA continued working until the end of the shift, contrary to policy requirements.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
The facility failed to ensure that food items stored in freezers, refrigerators, and dry storage areas were properly sealed, labeled, and dated, and that expired items were discarded as required by facility policy. During kitchen tours, surveyors observed multiple violations, including flour tortillas, salad mix, cut lettuce, blackberries, and pickles in the dry storage and walk-in cooler that were either past their use-by dates, not labeled with open or use-by dates, or visibly spoiled. In the walk-in freezer and reach-in freezer, items such as frozen corn, sausage, lasagna sheets, and chicken tenders were found without proper labeling or with expired use-by dates. Similar issues were found in the unit kitchen, where thickening agents, brown sugar, and cereals were not properly labeled, sealed, or dated, and some items were well past their best-by dates. Interviews with the Dietary Manager and dietary aide confirmed that the facility's expectations and policies require all food items to be labeled with received, open, and use-by dates, and that expired or spoiled items should be discarded. However, both staff members acknowledged that these procedures were not consistently followed, as evidenced by the presence of expired and improperly labeled food items. The Administrator also stated that her expectation is for food to be stored at proper temperatures and labeled and dated per policy, but acknowledged that oversight was not sufficient to prevent these deficiencies.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication as required by its own policies. The policies state that residents may self-administer medications only if the interdisciplinary team (IDT) determines it is clinically appropriate and safe, and this decision must be documented in the medical record and care plan. For the resident in question, who was admitted with diagnoses including orthostatic hypotension and syncope, there was no documentation of an order for self-administration, nor was there any mention in the care plan allowing the resident to keep medications at the bedside. Despite this, two nasal sprays with faded labels were observed in the resident's possession, and the resident reported using them independently for sinus issues. Record review showed the resident was cognitively intact, with a BIMS score of 15, but there was no evidence that the required assessment for self-administration had been completed prior to the resident keeping and using the medications. The facility's DON confirmed that the responsibility for determining self-administration eligibility lies with the RN and Medical Director, and acknowledged that the medications were reordered after it was discovered the labels were unreadable. The lack of assessment and documentation, as well as the presence of medications at the bedside without proper authorization, constituted a failure to follow facility policy and ensure safe medication practices.
Expired Medications Not Removed from Storage
Penalty
Summary
The facility failed to ensure that expired medications and biologicals were removed from the medication storage refrigerator, as required by facility policy and professional standards. During an observation, surveyors found one dose of Covid-19 vaccine and thirteen doses of Influenza Vaccine Adjuvanted with expiration dates that had already passed. Interviews with an LPN revealed uncertainty about who was responsible for discarding expired medications and how to properly dispose of them. The DON stated that while the pharmacist conducts monthly audits, nurses are expected to check for expired medications weekly during the day shift. Despite these policies, expired medications remained in the storage area, indicating a lapse in adherence to established procedures.
Deficiencies in Food Safety and Insulin Administration Practices
Penalty
Summary
The facility failed to ensure safe food handling and preparation when, during meal service, a dietary aide discovered metal can lids at the bottom of two separate pans of cooked apple crisp dessert. The aide, while plating the dessert, found a metal can lid in the first pan and discarded both the lid and the dessert, including any portions already plated. The same issue occurred with a second pan, resulting in the disposal of another lid and the dessert. Interviews with the dietary manager and cook confirmed that the apple crisp was prepared using canned ingredients, and the process involved removing the can lid and transferring the contents to a bowl. The administrator acknowledged that cooks are expected to check for foreign objects in food before serving. Additionally, the facility did not follow proper infection control practices during medication administration. An LPN was observed administering insulin without disinfecting the top of the insulin syringe with an alcohol wipe, contrary to both facility policy and manufacturer instructions. The LPN admitted to skipping this step due to haste. The incident was observed and confirmed by the Director of Nursing, who acknowledged the lapse in protocol.
Improper Use of Chemical Restraints with Haldol Administration
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Haloperidol Deaconate (Haldol) to a resident for exit-seeking behavior and entering patient rooms. The medication was not ordered for an approved indication of use, and the facility did not have systems in place to monitor for chemical restraints. The resident, who was admitted with diagnoses including Alzheimer's disease, type 2 diabetes, chronic obstructive pulmonary disease, and anemia, was given Haldol without a proper diagnosis or monitoring for adverse effects or behaviors. The resident's physician orders included an order for Haldol Deaconate 10 mg intramuscularly as needed for agitation, with a frequency that exceeded the usual recommendation. The medication was administered multiple times over a 17-day period without proper monitoring. Interviews with the Director of Nursing (DON) and the Nurse Practitioner (NP) revealed a lack of awareness and communication regarding the medication's intended use and the necessary diagnosis. The NP confirmed that the wrong medication was given and that the order was intended as a one-time dose only. Further investigation revealed that the pharmacy made a transcription error, leading to the incorrect administration of the medication. The facility's policy on the use of restraints was not followed, and there was a failure to obtain proper consents for psychotropic medications. The facility's systems for monitoring and documenting medication administration and side effects were inadequate, contributing to the deficiency.
Removal Plan
- The DON, MDS or Designee conducted an audit of residents to identify those residents with potential risk for chemical restraints.
- The DON, MDS Nurse, Administrator or Designee will conduct nurse and or provider in-service education of Guardian Pharmacy Psychotropic PRN Medication Regulation in LTC and medication Monitoring Management - Policy regarding F758 Psychotropic Medication and PRN use.
- The Director of MDS Nurse, Administrator or designee will conduct nurse inservice education on (6) rights of Medication Administration.
- The Director of MDS Nurse, Administrator or designee will conduct in-service/education on AASC Agitation in Alzheimer's Screener for Caregivers.
- The Director of MDS Nurse, Administrator or designee will conduct in-service/education on Policy for Medication Variance Report.
- The Director of MDS Nurse, Administrator or designee will conduct in-service/education on New Order Tracking Form.
- The Director of MDS Nurse, Administrator or designee will conduct in-service/education on CMS Revises Several Regulations in Appendix PP- Chemical Restraints/Unnecessary Psychotropic Medications.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a resident from eloping. On the evening of December 17, 2024, a resident with a history of Alzheimer's disease and cognitive impairment was found outside an exit door on the C-Unit of the facility. The resident, who was in a wheelchair, was discovered by an LPN after hearing an alarm and feeling cold air from the door. The resident stated he was picking berries from a bush outside. At the time, the weather was 54 degrees Fahrenheit. The resident had been admitted to the facility with diagnoses including acute respiratory failure with hypoxia, Alzheimer's disease, and muscle weakness. His Admission Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 00 out of 15, showing he was not cognitively intact. The resident exhibited delusions and verbal behavioral symptoms, and his wandering behavior placed him at significant risk of entering potentially dangerous areas. Despite these risks, the facility did not utilize electronic monitoring devices for residents at risk of elopement. The facility's policy required identifying residents at risk for elopement and implementing appropriate interventions. However, the resident's care plan, initiated on December 18, 2024, noted his elopement risk and wandering behavior but did not prevent the incident. The facility's Director of Nursing and Administrator were unable to recall when they were notified of the elopement, and the facility relied on a program called the 'Sunflower Program' to alert staff about high-risk residents, which was not sufficient to prevent the elopement incident.
Removal Plan
- Resident 1 was discharged from the facility to another facility.
- The Director of Nursing, MDS Nurse, Administrator or Designee will conduct an audit before admission and within 24 hrs after admission to evaluate residents for possible elopement risk, initiate interventions, notify MD and POA, then document on the Interim Care Plan. Residents identified at risk for elopement should be reassessed each quarter. Audit will continue daily for 3 months.
- The Director of Nursing, MDS Nurse or Designee conducted an audit of residents to identify those residents with potential elopement risk.
- The Director of Nursing and Administrator completed Elopement Risk Assessments for the residents identified to be a potential elopement risk, initiated interventions, notified MD and POA, then documented on the Interim Care Plan. Residents identified at risk for elopement should be reassessed each quarter.
- The Director of Nursing and Administrator initiated The Sunflower Elopement Program for those identified residents considered to be a potential elopement risk. A Sunflower magnet was placed on the resident's door, wheelchair and assistive device.
- The Director of Nursing and Administrator updated The Elopement Risk Binder with a profile page including a photo for those identified residents considered to be a potential elopement risk.
- The Director of Nursing and Administrator in-serviced/educated team members on the Sunflower Program-Elopement Risk Management & Interventions, signing acknowledgement of understanding and compliance. Team Members were also educated on the alarm system in use in the [NAME] SNF and are required to respond immediately to any exit door opening. In communities with a centralized alarm system, the control panel is in a team member accessible location. Inservice will be ongoing until all facility staff have signed off, during orientation and annually.
- An audit of the in-service/education training will be conducted by the administrator weekly and annually.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policy to protect a resident from alleged abuse. The policy mandates that appropriate steps be taken to protect residents during investigations of abuse, including removing the accused staff member from the premises. However, in this case, the CNA accused of being rough with a resident during toileting was not immediately removed from the building. Instead, the CNA was only removed from the specific resident's care but continued working in the facility until the end of the shift. The incident involved a resident who was cognitively intact and had a history of a displaced intertrochanteric fracture, sciatica, and hypothyroidism. The resident's daughter reported that the CNA handled her mother roughly, causing her pain and fear. Despite the LPN's awareness of the situation and communication with the DON, the CNA was not sent home immediately, contrary to the facility's policy. The DON and Administrator acknowledged the oversight, noting that the CNA should have been suspended pending the investigation.
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What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Patewood Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare - Greenville | 1.6 mi | ★★★★★ | 0 | 0 |
| Linville Court At The Cascades Verdae | 2.1 mi | ★★★★★ | 0 | 0 |
| Promedica Skilled Nursing And Reh- Greenville West | 2.7 mi | ★★★★★ | 1 | 0 |
| Rolling Green Village | 2.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.