Gem Transitional
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2022 1 penalties totaling $15,000
Fine
2021 1 penalties totaling $650
Fine
Health Violations by Year
2025 20 violations
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Implement a program that monitors antibiotic use.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024 8 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Provide and implement an infection prevention and control program.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2023 25 violations
Ensure that residents are fully informed and understand their health status, care and treatments.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide and implement an infection prevention and control program.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2022 17 violations
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure that residents are free from significant medication errors.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
2021 2 violations
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide and implement an infection prevention and control program.
2020 2 violations
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2019 9 violations
Reasonably accommodate the needs and preferences of each resident.
Ensure each resident receives an accurate assessment.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Have enough outside ventilation via a window or mechanical ventilation, or both.
2018 30 violations
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assure that each resident’s assessment is updated at least once every 3 months.
Ensure each resident receives an accurate assessment.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide safe, appropriate pain management for a resident who requires such services.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
2017 19 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure medication error rates are not 5 percent or greater.
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.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Keep all essential equipment working safely.
Have enough outside ventilation via a window or mechanical ventilation, or both.
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.