Emeritus At Greenville

F-F605, constituting substandard quality of care.

Findings include:

Review of the Manufacturer's Recommendation for the medication Haldol revealed, Increased Mortality in Elderly Patients with Dementia-Related Psychosis treated with antipsychotic drugs are at an increased risk for death. Observational studies show that, similar too atypical antipsychotics drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to antipsychotic drugs as opposed to some characteristics of patient is not clear. Haldol Deaconate 50 and Haldol Deaconate 100 are indicated for the treatment of patients with schizophrenia who required prolonged antipsychotic therapy.

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 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0605 Review of the undated facility policy titled, Use of Restraints revealed under the policy, Ensure that chemical restraints are only used when needed to treat the residents medical symptoms and then, only use the least Level of Harm - Immediate restrictive alternate for the least amount of time. Prior to the initiation of psychotropic medication, clinicians jeopardy to resident health or will thoroughly assess resident's mental/cognitive, behavior and physical status. This assessment will safety address other interventions that may be symptoms or the cause of the situation. A physicians order is necessary for the initiation of any restraint or psychotropic medication . that order will include the physicians Residents Affected - Few diagnosis .it will also include the expected duration.

Record review of Resident R1's facesheet revealed he was admitted to the facility on [DATE REDACTED] with diagnoses that include but are not limited to Alzheimer's disease, type 2 diabetes, chronic obstructive pulmonary disease and anemia.

Review of Resident R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24 revealed the Brief Interview for Mental Status (BIMS) score could not be conducted and was checked as, rarely understood.

Review of Resident R1's Physician orders revealed, an order dated 12/21/24 for Haldol Deaconate Inject 0.2 milliliter (ml) 10 milligrams (mg) intramuscularly (IM) as needed for agitation. Every 8 hours. End date Indefinite. It had 3 warnings, including Back Box warning, Alert Dose warning and Drug interaction warning. The alert dose warning stated, The frequency of daily exceeds the usual frequency of every 28 days.

Record review of Resident R1's medication administration record (MAR) dated December 24 revealed Resident R1 received 3 doses of Haldol Deaconate, recorded as given on 12/21/24, 12/23/24 and 12/29/24. The medication remained active on Resident R1's MAR for 17 days. There was no monitoring of the medication for adverse effects or behaviors.

Review of Resident R1's care plan dated 12/17/24 revealed, [Resident R1 uses psychotropic medications, dementia and that he will be free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment.]

Record review of Resident R1's progress notes dated 12/21/24 at 01:58 revealed Licensed Practical Nurse (LPN)1 reported exit seeking behavior, entering patient rooms and is in constant need of redirection. [Nurse Practitioner] NP called back and said she will fax order in the morning and stated he can have 10 mg IM of Haldol.

Record review of a fax confirmation dated 12/21/24 revealed an order from the NP for Haldol 10 mg IM x 1, as needed for agitation for Resident R1. This was received at 6:00 PM.

Record review of the Emergency Drug Kit #1 revealed there was Haloperidol 5 milligram/milliliter injection in

the drug kit.

Record review of Resident R1's Order Audit Form revealed 2 dates the pharmacy sent the Haldol Deaconate, on 12/21/24 and 12/27/24.

Record review of the pharmacy packing slip dated 12/21/24 and 12/28/24 revealed Resident R1's medication of Haloperidol Deaconate was delivered to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0605 During an interview on 02/06/25 at 4:30 PM, with the Director of Nursing (DON) revealed, that she monitors

the antipsychotic medication, and the scripts are for 14 days. The DON stated she was not aware the Level of Harm - Immediate medication had been ordered for longer than 14 days without a diagnosis. She said the physician should give jeopardy to resident health or the diagnosis and the nurses should ask. She stated, I am aware the NP was called for Resident R1 when the order safety was given.

Residents Affected - Few On 02/06/25 at 5:07 PM, an interview with the NP confirmed she was the on-call provider and did order an injection. She stated, As far as I know, yes, he can receive that, we do give Haldol sometimes. I know of the Black Box Warning. I've never received an alert dose warning on administration like that. For acute conditions, it can be anywhere from 1 to 5 to 10 mg. The maximum daily dose is 20 mg. We were trying to choose medication from their formulary. I didn't specify a diagnosis. I didn't get a call back on the warning. Ordering every 8 requires constant monitoring. I'm concerned it may have been a 1-time order. I need to

review my documentation on this and refer to my Physician and I will call you back. I'll get clarification on the Haldol Deaconate versus the Haldol injection.

On 02/06/25 at 5:30 PM, during a follow-up interview with the NP, revealed, Regular Haldol is not the same as Haldol Deaconate, it's usually given once a month. The NP said, They gave the wrong medication, and confirmed she ordered the Haldol 10 mg, as a 1 time dose only.

During a follow up interview with the DON at 6:25 PM, the DON stated she spoke to the NP and she said it was the wrong medication. The DON stated, Somehow the pharmacy ordered it as a 1-time dose as needed, and it ended up being input as 0.2 mg IM Q 8 hours. We expect the nurses to ask for the diagnosis. If the pharmacy puts it in correctly, the behaviors and the side effects would be there, but they did not. Those warnings are confirmed by the nurse after the order is placed by the pharmacy. The DON also stated, I believe those warnings also go to our Medical Director.

During an interview on 02/06/25 at 7:38 PM, LPN1 stated, Resident R1 was exit seeking and trying every door. We would try to redirect him, and he was aggressive and very unaware of his surroundings. We had given him Ativan, it didn't help. So, I called the NP on call. She asked me what all his medications were. She said she was going to put an order in for Haldol and to discontinue the Ativan. She said to wait for the fax order, but don't give it until confirmed with the pharmacy.

On 02/07/25 at 10:20 AM, a follow up interview with the DON revealed, I spoke to pharmacy several times yesterday and they confirmed it was their transcription error for Resident R1's Haldol. A request was made by the surveyor to review the Haldol removed from the drug kits in December 24. The DON said, Our Social Services Director (SSD) does the consents for Psychotropic medications. She was not doing that.

On 02/07/25 at 10:45 AM, a phone interview was conducted with the Pharmacist Consultant. She said, When

the nurse gets the order and it is available, they can get the medication from the e-kits. The pharmacy enters

the orders into the system and pushes it back over into their electronic system. The facility can also enter orders. After hours, if the medication is not a controlled med, the nurse can pull the medication from the e-kit without going through the pharmacy to open the kit, that is not required. The regular Haldol is short acting,

the other was long acting. Excessive lethargy and multiple drug interactions are just a few adverse effects that can occur. The nurses should be monitoring for drug side effects, and behaviors. The facility is responsible for putting those behaviors and side effects into the system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0605 On 02/07/25 at 11:15 AM, an interview was conducted with the Pharmacy Director. He confirmed they did in fact send the Haldol Deaconate, and confirmed that was a pharmacy error. He stated, The medication was a Level of Harm - Immediate 1-time only order, not every 8 hours. I'm not sure where that came from. jeopardy to resident health or safety The facility's removal plan dated 02/07/25;

Residents Affected - Few 1) Resident R1 was discharged from the facility to another facility on 01/06/25.

2) Immediately on 02/07/25, the DON, MDS or Designee conducted an audit of residents to identify those residents with potential risk for chemical restraints.

3) Immediately on 02/07/25, 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

F-F689 on 02/05/25.

An extended survey was conducted in conjunction with the Complaint Survey as a result of substandard quality of care.

Findings include:

Review of the facility's policy titled, Elopement Risk-RM-2, Category/Sub-Function: Clinical Services, Applies to: Skilled Nursing Communities with a revision date of 07/2015 revealed, Policy Overview: Residents who are at risk for elopement should be identified. Elopement occurs when a cognitively impaired resident leaves

the community undetected and unsupervised.

A. Evaluating for Elopement Risk Prior to Admission.

1) Admission Associate will identify potential risk for elopement and notify the Director of Clinical Services/designee of the following:

The resident has a pertinent diagnosis of dementia, Alzheimer's/anxiety disorder, delusions and is the resident currently capable of independent mobility.

A history of exit seeking, wandering away, or getting lost.

A history of unmet needs, alcohol or drug abuse.

2) The Interdisciplinary Team will approve/decline all potential admissions based on the resident's exit seeking/elopement risk and safety measures in place at the Community.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 B. Admission to and/or Residence within the Community

Level of Harm - Immediate 1) Resident accepted for admission will be assessed upon admission into the Community and appropriate jeopardy to resident health or interventions will be established to respond to the resident's potential exit/elopement seeking behavior. safety 2) Intervention may include, but are not limited to: Residents Affected - Few Frequent monitor (Q 15-minute checks)

Activities specific to resident needs

Family/companion services

Electronic Monitoring/Elopement System

Pain Management

Room Location

Assess for cause of Delirium signage placed to assist resident with directions to room.

Knowledge of dominant hand

3) Completion of Elopement Risk Data Sheet with photograph. Place in Elopement Risk binder at Nursing Station and/or Receptionist Desk.

4) Communication of Elopement Risk to nursing associates and ancillary departments.

5) Director of Clinical Services or designee will review and maintain the accuracy of Resident Identification and Wandering Resident Binders.

6) Residents will be assessed on admission and a minimum of quarterly or as condition change warrants.

7) Interventions will be documented in the Resident's Plan of Care and reviewed/updated a minimum of quarterly or as condition warrants.

C. Additional Interventions for Communities with Resident Monitoring System

1) The Admission Team will assess the resident for appropriate placement of the Community's wandering resident monitor system on admission and a minimum of quarterly or as condition change warrants to promote resident safety in least restricted environment.

2) Interventions/approaches will be documented in the Resident's Plan of Care and reviewed/updated a minimum of quarterly or as conditions warrants.

3) Initiate Resident Monitoring System as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 Obtain Physician Orders for monitoring system.

Level of Harm - Immediate Inform resident/legal representative. jeopardy to resident health or safety Apply the personal monitoring device in accordance with the manufacturer's instructions.

Residents Affected - Few Monitor resident's comfort relative to the fit of device.

Verify proper functioning of alarm after application by following manufacturer's activation instructions.

Record review of Resident R1's Face Sheet revealed he was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to; acute respiratory failure with hypoxia, Alzheimer's disease, age related physical debility, and muscle weakness.

Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24 revealed Resident R1 has the Brief Interview of Mental Status (BIMS) score of 00 out of 15, which indicates that he is not cognitively intact. Further review of the MDS revealed that during the assessment period, Resident R1 had delusions (misconceptions or beliefs that were firmly held and contrary to reality. Further review of the Admission MDS revealed Resident R1 had verbal behavioral symptoms directed towards others (threatening others occurred one to three days during the assessment. Resident R1's behavioral impact significantly interfered with the residents care and interfered with the resident's participation in activities/ social interactions. Resident R1 had a wandering presence, and this behavior occurred four to six days but less than lately and wandering placed

the resident at significant risk of getting into a potentially dangerous place during this assessment period.

Record review of Resident R1's Electronic Medical Record (EMR) Care Plan revealed Focus: The resident is an elopement risk/wanderer AEB [as evidenced by] Disoriented to place, History of attempts to leave community unattended, Impaired safety awareness, Resident wanders aimlessly Goal: The resident will have no injury related to exit seeking behavior through the next review date. Date Initiated: 12/18/2024 Interventions/Tasks include Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers. Identify pattern of wandering. Intervene as appropriate.

Record review of Resident R1's EMR Nurses Notes dated 12/17/24 revealed Patient continues to exit seek, he has attempted to exit out of all 3 doors, I have called and spoke with Resident R1's Resident Representative (RR)2 however, he is out of state and stated that patient was restrained while in the hospital. I then called Resident R1's other Resident Representative (RR)1 to come and sit with the patient. However, I got a voicemail and left a message, Director of Nursing (DON) and Assistant DON aware of patient's exit seeking behaviors, patient is now in day area wit the TV.

Record review of Resident R1's EMR Nurses Note dated 12/18/24 of a Comprehensive Nursing Note revealed Patient is alert and oriented X1. Patient can recall past events, patient continues to receive skilled nursing care, patient is exit-seeking and trying doors throughout the shift. Patient medicated per Medication Administration

Record (MAR), patient is now resting in his bed eye closed and RR1 present, bed is low and locked with fall mat on the ground.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 Record review of Resident R1's EMR Nurses Notes dated 12/18/24 revealed On 12/17/24 at 9:33 PM, Resident R1 was exit seeking at the end of hall C. LPN1 was in a room passing medications when she returned, she felt cold air Level of Harm - Immediate coming through the door and the alarm sounds from the door at the end of hall C. She discovered the jeopardy to resident health or resident outside. He stated he was picking berries from a bush by the door. No injuries were noted . safety appropriate parties were notified. A state reportable was made regarding the incident, a body audit and elopement risk assessment was completed on admission and again on 12/18/24. Investigation is in progress; Residents Affected - Few the front lobby door was on lock down on 12/17/24.

Record review of Resident R1's EMR Social Services Progress Note dated 12/18/24 revealed Writer attempted to call Resident R1's RR1 to get admission paperwork and discuss getting a sitter, no answer.

Record review of Resident R1's EMR General Note dated 12/18/24 revealed New admit on 12/16/24 following hospital stay for acute respiratory failure. He has Alzheimer's dementia with sundowning behavior. He arrived soaked

in urine from hospital, needed bath. Had been strapped in bed prior to admit, difficult to redirect propels self around facility. Elopement out of C- door evening before, prior to hospital has been in multiple facilities, son wants to send back to previous facility. Speech Therapy observed Resident R1 standing and messing with clothing, he did sit when asked but upset pants do not fit well and will not fasten. Social Services to notify daughter of need for clothing, working with Physical Therapy and Occupational Therapy.

Record review of Resident R1's EMR Nursing Note dated 12/18/24 revealed Resident has increased agitation, behaviors, exit seeking behavior. Resident being constantly redirected, constant supervision needed.

Record review of Resident R1's EMR General Note dated 12/19/24 revealed Documentation for 12/18/24 attempted to call Resident R1's RR1 and was unsuccessful, was able to contact RR2. RR2 stated that he will be willing to check into a private sitter, spoke with RR1 and they stated they were unable to drive at night due to poor vision and working during the day, unable to be present with Medical Director (MD) visit but will be available by phone.

An interview on 02/05/25 at 12:11 PM with Licensed Practical Nurse (LPN)1 revealed Resident R1 was constantly attempted to exit-seek throughout that evening and night and was unable to be redirected. I was passing medications in another resident's room and when I finished, I heard the alarm to the door sounding off and I also felt a cool breeze down the hallway as well. When I found the resident, his was in his wheelchair and right beside the door and attempting to pick the berries from off the bush. The resident had been outside alone for about 30 seconds prior to me coming outside and finding him.

An observation and interview with LPN1 on 02/05/25 at 12:25 PM revealed the location of where Resident R1 eloped from the facility, at the time of the observation the door was in working order.

Record review of LPN1's Witness Statement dated 12/17/24 revealed I heard (the) alarm door and walked from A-Hall towards (the) Nurses Station, I felt cold air and walked towards C-Hall door and it was opened. Resident R1 was just outside the door in his wheelchair. The resident's Certified Nursing Assistant (CNA) was in (the) dayroom, the other staff member was on the B-Hall. I called to them and they helped me get Resident R1 inside safely, no harm to patient.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 A phone interview on 02/05/25 at 2:37 PM with RR1 revealed that they were notified when the resident eloped from the facility on 12/17/24. RR1 further stated that when the facility notified her of the resident's Level of Harm - Immediate elopement they insisted that they hire a private sitter to adequately supervise Resident R1. RR1 stated, I refused to jeopardy to resident health or pay anyone to sit with Resident R1 because it's their job (the facility) to make sure he doesn't get out. RR1 further safety mentioned that they felt pressure by facility staff to hire an outside sitter but did not because of the financial strain. Residents Affected - Few

An interview with the Director of Nursing (DON) and Administrator on 02/05/25 at 5:37 PM, revealed that

they were unable to recall when exactly they were notified of Resident R1's elopement from the facility because it happened at night. The DON further stated that the facility does not utilize electronic monitoring devices on residents that are at risk for elopement, but have a program called the 'Sunflower Program' that alerts staff to keep an extra eye on those high-risk residents. The DON further stated that after Resident R1 eloped from the facility,

they spoke with Resident R1's family to determine if they could hire a private sitter for extra supervision for Resident R1. When it was determined that was not feasible for Resident R1's family, Resident R1 was moved to a room closer to the nurse's station and was placed on the Sunflower Program to alert staff of his high-risk elopement status. Further interview with the Administrator and DON revealed that the facility does not currently have electronic monitoring devices for the residents and staff are to monitor residents adequately.

The facility's removal plan included the following:

1. Resident 1 (who allegedly eloped) was discharged from the facility to another facility on 01/06/2025.

2. 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.

3. Immediately on 2/5/25-The Director of Nursing, MDS Nurse or Designee conducted an audit of residents to identify those residents with potential elopement risk.

4. Immediately on 2/5/25-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.

5. Immediately on 2/5/25-The Director of Nursing and Administrator initiated The Sunflower Elopement Program was 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.

6. Immediately on 2/5/25-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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 7. Immediately on 2/5/25-The Director of Nursing and Administrator in serviced/educated team members on

the Sunflower Program-Elopement Risk Management & Interventions, signing acknowledgement of Level of Harm - Immediate understanding and compliance. Team Members were also educated on the alarm system in use in the jeopardy to resident health or [NAME] SNF and are required to respond immediately to any exit door opening. In communities with a safety centralized alarm system, the control panel is in a team member accessible location. lnservice will be ongoing until all facility staff have signed off, during orientation and annually. Residents Affected - Few 8. An audit of the in-service/education training will be conducted by the administrator weekly x 6 weeks and annually.

Monitoring and Follow-up Plan:

The facility will monitor compliance with the corrected procedures to ensure the IJ issue does not recur by:

1. Reminders of At- Risk residents at Daily Stand-Up and by DON/ADON/Nurse Supervisors each shift.

2. Weekly At- Risk Meetings of each resident identified at-risk: Review effectiveness of interventions in place and/or recommended change in interventions and update team members, MD and POA. Residents identified at risk for elopement will be reviewed each week during the At-Risk Meeting. Elopement prevention interventions will be developed for the individual resident and communicated to team members, MD and POA. EHR/ PCC was updated with these identified interventions.

3. Inclusion ofTherapy ie.PT/ OT/ST, plus IDT team members and ED in determination of appropriate therapy and other interventions as identified.

4. To maximize safety for residents in the community, each exit door at The [NAME] SNF is equipped with a sounding alarm device that is activated when the door is opened. In some communities, this is audible and of sufficient volume to be heard by team members.

5. Include plans for ongoing staff education of new and existing staff, monthly elopement drills, competency assessments and any noted areas of identified improvements related to the IJ issue.

6. The Administrator will send in audit findings to corporate compliance and bring to QAPI for review monthly.

Anticipated Correction Date 02/05/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 425373

F-F758 Psychotropic Medication and PRN use.

4) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct nurse inservice education on (6) rights of Medication Administration.

5) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on AASC Agitation in Alzheimer's Screener for Caregivers.

6) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on Policy for Medication Variance Report.

7) Immediately on 02/07/25 the Director of MDS Nurse, Administrator or designee will conduct in-service/education on New Order Tracking Form.

8) Immediately on 02/07/25 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.

Monitoring and Follow Up Plan;

The facility will monitor compliance with the corrected procedures to ensure the IJ issue does not recur by;

1. Reminders of At- Risk residents at Daily Stand Up and on 24 HOUR NURSE REPORT by DON/ADON/Nurse Supervisors each shift.

2) Weekly Ad Hoc Meetings of each resident identified AT Risk: Review effectiveness interventions in place and/or recommended change in interventions and update team members, MD, and POA. Behavioral interventions will be developed for the individual resident and communicated to team members, MD, and POA. EHR/PCC was updated with these identified interventions.

3) Inclusion of Therapy ie; PT/OT/ST, plus IDT team members and ED in determination of appropriate therapy and other interventions as identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0605 4) Inservice will be ongoing until all appropriate facility have signed off, during orientation and annually.

Level of Harm - Immediate 5) An audit of the inservice/education training will be conducted by the Administrator weekly x 6 weeks and jeopardy to resident health or annually. safety 6) The Administrator will send in audit findings to corporate compliance and bring to QAPI for review monthly. Residents Affected - Few 7) Anticipated correction date 02/07/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48835 potential for actual harm Based on review of the facility policy, interviews, and record review, the facility failed to implement their Residents Affected - Few policy, Abuse Prevention Program to provide protection for the identified resident (Resident (R)4) for 1 of 3 residents reviewed for abuse.

Findings include:

Review of the undated facility policy titled, Abuse Prevention Policy states under the policy, The abuse prevention program provides policies and procedures that govern at a minimum; protection of residents

during investigations of abuse, including prohibiting and preventing retaliation. Under Procedure 4, Appropriate steps will be taken, as directed by the administrator to provide protection for the identified resident prior to conducting the investigation of the alleged violation.

Record review of the facility's facesheet revealed Resident R4 was admitted on [DATE REDACTED] with diagnosis including but not limited to; displaced intertrochanteric fracture right femur, sciatica right side, and hypothyroidism.

Record review of Resident R4's Minimum Data Set (MDS) with an Assessment Reference Date of 10/09/24 revealed Resident R4's Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicating she was cognitively intact.

Record review of the South Carolina Department of Public Health (SCDPH) report submitted on 12/13/24 revealed an allegation of neglect or exploitation, suspected or confirmed abuse stated, reported to Licensed Practical Nurse (LPN), Certified Nurse Assistant (CNA) had been rough with her during toileting and her mother called her multiple nights and is afraid. CNA has been removed from the floor.

An interview with LPN1 on 02/06/25 at 10:55 AM revealed she worked the night of the allegation and remembered the daughter came up here and overheard a conversation with the CNA and witnessed, The CNA jerked the covers off her mom and was handling her roughly. I called my Director of Nurses (DON) and was told to Take CNA off her mom's assignment. She continued the same assignment, just not that room. I learned in the morning I was supposed to have CNA leave the building right away, that if there is an allegation of abuse, the person is supposed to leave the building right away to determine if it was actual abuse.

An interview with Resident R4's daughter on 02/06/25 at 12:09 PM, confirmed she came in during the night because her mom called. She stated, She was confused and thought she'd been kidnapped. Mama's light was on. There were people in the room. I said get away from my mother, I'll take care of her. She pushed mom's leg that had the surgery, and it hurt my mom. She told mom, you can pee 5 times in that diaper. Mother had a Urinary Tract Infection (UTI). She told me she was scared to death of her and was afraid she was going to be killed by the nurse. They didn't allow the lady back in there. I stayed all night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0607 An interview with the DON on 02/06/25 at 1:30 PM revealed, The LPN called me that night. She was accusing the CNAs of being rough. I told her to start gathering witness statements. It was aimed at CNA1. Level of Harm - Minimal harm or She was removed from her care. She was asked not to go back in there. When I came in, it was right at the potential for actual harm end of the shift. I make the determination of an allegation after I gather the information. I should make the allegation of abuse and had her gather the information. It sounds like I probably should have asked her Residents Affected - Few (LPN) to send her home. When it is an allegation of abuse, the policy states that we would send them home pending an investigation. The employee was suspended that morning. She had already left for the day, she went home.

An interview with the Administrator on 02/06/25 at 1:51 PM revealed, I am the abuse coordinator. If an incident happened, she, (the DON) gets the records and statements. When we have an allegation, we will suspend the person who was named. Then we will investigate it out. I think it was on 12/13/24. Around 7:03 AM, the DON informed me of it. The daughter reported to the LPN that the CNA had been rough with her.

The CNA had been removed from the floor. She should have been asked to go home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 425373 Department of Health & Human Services Printed: 09/09/2025 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 425373 B. Wing 02/10/2025

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

The Gables of Pelham Skilled Nursing & Rehab 1306 Pelham Rd Greenville, SC 29615

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42424 safety Based on review of the facility policy, record review, and interviews, the facility failed to ensure that adequate Residents Affected - Few supervision was in place to prevent Resident (R)1 from eloping from the facility.

On 12/17/24 at approximately 9:33 PM, Resident R1 was found outside of an exit door on the C-Unit of the facility. Licensed Practical Nurse (LPN)1 stated that they heard the alarm sounding off from another unit and felt cold air coming from the door while walking down the hallway. Resident R1 was observed outside of the door in his wheelchair and stated that he was picking berries from the bush. On 12/17/24 at approximately 9:33 PM, the weather was 54 degrees Fahrenheit (F).

On 02/05/25 at 7:34 PM the Administrator was electronically notified that the failure to ensure Resident (R)1 was free from accidents/hazards related to a succesful elopement on 12/17/24 constituted Immediate Jeopardy (IJ). The IJ was related to S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

On 02/06/25 at 10:40 AM the facility provided an acceptable IJ Removal Plan. On 02/06/25 at 10:40 AM, the survey team validated the facility's corrective action and verified the removal of the IJ related to