The Gables of Pelham Skilled Nursing & Rehab

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled and dated with a use by date and/or discarded after the manufacturer's expiration date. In 2 of 2 Kitchens, 1of 2 Freezers, 1 of 2 Refrigerators and 1 of 1 Dry Foods Storage.Review of the facility's policy titled Food Receiving and Storage last revised July 2024 revealed, Foods shall be received and stored in a manner that complies safe food handling practices. 7) Dry foods that are stored in bins will be removed from original packing, labeled and dated (use by date). Such food will be rotated using a first in - first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date) . 14. C. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. E. other opened containers must be dated and sealed or covered during storage.During the initial kitchen tour on 07/22/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record reviews, observation and interviews, the facility failed to assess a resident for safe self-administration of medication for 1 of 1 resident, Resident (R) 34 reviewed for self-administration of medication.Review of the facility policy titled, Self-Administration of Medication last revised February 2021, states, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.1. As a part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observations and interviews, the facility failed to ensure that expired medications and biologicals were removed from the refrigerator in 1 of 1 medication storage rooms.Review of the facility policy titled Medication Labeling and Storage last revised February 2023, states 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.During an observation of the medication storage room on 07/22/25 at 12:25 PM, the following was observed:1. 1 dose of Covid 19 Vaccine with an expiration date of 05/09/252. 12 doses of Influenza Vaccine Adjuvanted with an expiration date of 04/24/253. 1 does Influenza Vaccine Adjuvanted with an expiration date of 06/02/25. During an interview on 07/22/25 at 12:33PM, Licensed Practical Nurse (LPN)1 stated, I was unable to determine who was responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, manufactures instructions, observations and interviews, the facility failed to: 1. Ensure the safe handling and preparation of meals when during meal preparation a metal can lid was noted in a pan of cooked desert 2. Follow appropriate infection control practices during medication administration when Licensed Practical Nurse (LPN)1 failed to clean the top of the insulin syringe before administration of insulin. 1. Review of the facility's policy, titled Food Preparation and Service, last revised November 2022, revealed, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.During an observation of the main kitchen on 07/23/25 at 11:44 AM a Dietary Aide (DA) was observed plating an apple crisp dessert when she pulled a metal can lid out of the bottom of the prepared pan with her gloved hand. She then discarded the lid into the trash, followed by the contents of the pan and any dessert that had already been plated. The DA then proceeded to use a second prepared pan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, interviews, and record review, the facility failed to implement their 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 R4 was admitted on [DATE] with diagnosis including but not limited to; displaced intertrochanteric fracture right femur, sciatica right side, and hypothyroidism. Record review of R4's Minimum Data Set (MDS) with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, observation, and interview, the facility failed to ensure that 1 of the 2 dumpsters were kept closed to keep pests out and/or to keep the garbage contained in the dumpsters. The facility also failed to ensure the area around the dumpster was clean and free of debris and failed to ensure the other dumpster was clean. This failure had the potential to cause insects and rodents near the dumpster, which could potentially be a health hazard. Findings include: Review of the policy Disposal of Garbage/Rubbish, dated 05/02/21 provided by the Executive Director documented .All garbage and rubbish containing food wastes will be kept in container .Garbage and rubbish containing food wastes will be stored in such a way that it is inaccessible to vermin. Storage areas will be always kept clean. Outside dumpsters provided by garbage pickup services will be kept closed and the surrounding area will be kept free of litter . Observation and interview with the Maintenance Director (MD) on 06/29/22 at 12:15 PM revealed the dumpster used for garbage and trash had a missing door,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, the facility failed to notify the resident representative in a timely manner, for an accident with change of condition for 1 resident Resident (R) 24 of 6 residents reviewed for falls/accidents. Findings include: Review of the undated policy titled Condition Change of the Resident, revealed the procedure to be Documentation guidelines .Notification of the resident's responsible party, including date and time. Review of a Progress Note documented by Licensed Practical Nurse (LPN) 1, located in the Progress Note tab of R24's electronic medical record (EMR) and dated 05/10/22 at 7:15 PM, revealed Nursing staff was in room with patient providing ADL [activity of daily living] care, during care patient turned onto right side, brief was being placed onto patient, patient started to move and started to roll off the bed Nursing staff was able to assist patient by lowering her to the floor safely. Patient was assisted back into the bed by two staff members. Patient c/o [complained of] pain in right knee currently, on call from [name of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, observations and interviews, the facility failed to ensure that 2 residents, Resident (R)14 and R22, of 3 residents reviewed for provision of activities of daily living (ADL) out of a total sample of 12 residents, received appropriate grooming, specifically related to the removal of facial hair. Failure to remove facial hair for a resident could result in a decrease in body image, depression, and isolation. Findings include: Review of the Shaving the Resident policy, dated 05/22/21, revealed it was the basic responsibility of the licensed nurse, Certified Nursing Assistant (CNA) .to remove facial hair to improve the resident's appearance and morale . 1. Review of R14's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated R14 was admitted to the facility on [DATE], with diagnoses of dementia without behavioral disturbance and major depressive disorder. Review of R14's annual Minimum Data Set (MDS) located in the EMR under the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.