The Gables Of Pelham Skilled Nursing & Rehab
THE GABLES OF PELHAM SKILLED NURSING & REHAB in GREENVILLE, SC — inspection on February 10, 2025.
Found 3 citations. 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
Review of 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 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 R1's medication administration record (MAR) dated December 24 revealed 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 R1's MAR for 17 days.
There was no monitoring of the medication for adverse effects or behaviors.
Review of R1's care plan dated 12/17/24 revealed, [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 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 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 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 R1's medication of Haloperidol Deaconate was delivered to the facility.
425373
Form Approved OMB
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
Investigation is in progress;
Record review of R1's EMR Social Services Progress Note dated 12/18/24 revealed Writer attempted to call R1's RR1 to get admission paperwork and discuss getting a sitter, no answer.
Record review of 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 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 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 R1's EMR General Note dated 12/19/24 revealed Documentation for 12/18/24 attempted to call 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 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 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. 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 R1 inside safely, no harm to patient.
425373
Form Approved OMB
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
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.
425373
Form Approved OMB
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