Cycle 1
Health 2025-07-24 · Fire 2025-07-24
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Greenville, SC
The Gables Of Pelham Skilled Nursing & Rehab
2-star overall rating with 2-star inspections with $11,196 in total fines with 4 recent health deficiencies
1306 Pelham Rd, Greenville, SC
(864) 286-6600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-07-05
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.52
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
78%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,905
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.45
Baseline 20.54% · Performance 19.37% · Measure score 4.45 · Achievement 4.45 · Improvement 2.82
Healthcare-associated infections
1.26
Baseline 7.58% · Performance 7.46% · Measure score 1.26 · Achievement 1.26 · Improvement 0
Total nurse turnover
3.21
Baseline 73.08% · Performance 55.17% · Measure score 3.21 · Achievement 2.08 · Improvement 3.21
Adjusted total nurse staffing
2.45
Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 15.71% · Lower 95% interval 8.33% |
| Discharge to community | 42.62% |
50.57%
8 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 37.5% · Lower 95% interval 33.25% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 89 · Denominator 89 |
| Falls with major injury | 8.99% |
0.77%
8.2 pts worse
|
Numerator 8 · Denominator 89 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 26 · Denominator 48 |
| Discharge mobility score | 58.33% |
50.94%
7.4 pts better
|
Numerator 28 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 2.25% |
2.29%
About the same
|
Numerator 2 · Denominator 89 · Adjusted rate 2.12% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 5.36% |
42%
36.6 pts worse
|
Numerator 3 · Denominator 56 |
| Discharge function score | 60.42% |
56.45%
4 pts better
|
Numerator 29 · Denominator 48 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 42 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 20.75% |
25.2%
4.4 pts worse
|
Numerator 11 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.8 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
90.5%
6.5 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 95.7% · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.0%
1.5 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 8.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
2.9%
1.3 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
6.2%
4.9 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.0% |
20.4%
9.6 pts worse
|
19.6%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
16.3%
7.5 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
12.4%
14.5 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.6%
1.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
17.2%
5.2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 32.2% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.8%
2.3 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.5% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
79.8%
13.2 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 94.1% · Q3 92.9% · Q4 85.7% · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
14.1%
4.6 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 16.9% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.8% |
1.6%
5.2 pts worse
|
1.6%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.0% · Q3 5.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.1% |
78.0%
14.1 pts better
|
79.7%
12.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
24.7%
4.7 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 26.2% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-06-30 · Fire 2022-06-30
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-02
D · Potential for more than minimal harm
2022-06-30
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-07-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-24
D · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-24
J · Immediate jeopardy
2025-02-10
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-03-11
J · Immediate jeopardy
2025-02-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-11
F · Potential for more than minimal harm
2022-06-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-22
Penalties and ownership
What sits behind the stars
$5,598
2025-02-10
Fine
Fine · fine $5,598
Fine
$5,598
2025-02-10
Fine
Fine · fine $5,598
Fine
Ownership
Fsl Senior Living Ventures, LLC
5% Or Greater Direct Ownership Interest · Organization
Fc Senior Living Investments, LLC
5% Or Greater Indirect Ownership Interest · Organization
Foster Senior Living, LLC
5% Or Greater Indirect Ownership Interest · Organization
Foster, John
Operational/Managerial Control · Individual
Foster, John
Corporate Officer · Individual
Fsl Senior Living Ventures, LLC
Operational/Managerial Control · Organization
Willard, Susan
Operational/Managerial Control · Individual
Willard, Susan
Corporate Officer · Individual
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#3
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4-star overall rating with 3-star inspections with $7,446 in total fines with 2 recent health deficiencies
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