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Gem Transitional

📍 716 South Fair Oaks Ave, Pasadena, CA 91105 📞 (626) 737-0560 🛏️ 75 beds

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.

May 16, 2025 Complaint Investigation

Fines and Penalties by Year

2022 1 penalties totaling $15,000

$15,000
Oct 28, 2022

Fine

2021 1 penalties totaling $650

$650
Jun 28, 2021

Fine

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Health Violations by Year

2025 20 violations

Tag 0627 D May 17, 2025

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

✓ Corrected: Jun 12, 2025
Tag 0689 G May 16, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jun 11, 2025
Tag 0742 J May 16, 2025

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.

✓ Corrected: Jun 11, 2025
Tag 0881 E May 8, 2025

Implement a program that monitors antibiotic use.

✓ Corrected: May 11, 2025
Tag 0882 E May 8, 2025

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

✓ Corrected: May 11, 2025
Tag 0607 D May 7, 2025

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

✓ Corrected: May 11, 2025
Tag 0609 D May 3, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: May 11, 2025
Tag 0806 D May 3, 2025

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

✓ Corrected: May 11, 2025
Tag 0689 D Apr 28, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: May 9, 2025
Tag 0806 D Apr 28, 2025

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

✓ Corrected: May 9, 2025
Tag 0689 D Apr 1, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Apr 25, 2025
Tag 0756 D Apr 1, 2025

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Apr 25, 2025
Tag 0686 D Mar 20, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Apr 8, 2025
Tag 0609 D Feb 25, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Mar 21, 2025
Tag 0657 D Feb 25, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Mar 21, 2025
Tag 0684 D Jan 29, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: Feb 20, 2025
Tag 0803 E Jan 13, 2025

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.

✓ Corrected: Jan 31, 2025
Tag 0804 E Jan 13, 2025

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

✓ Corrected: Jan 31, 2025
Tag 0812 E Jan 13, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Jan 31, 2025
Tag 0689 E Jan 7, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Feb 1, 2025

2024 8 violations

Tag 0550 D Aug 28, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Sep 19, 2024
Tag 0558 E Aug 28, 2024

Reasonably accommodate the needs and preferences of each resident.

✓ Corrected: Sep 19, 2024
Tag 0880 D Aug 21, 2024

Provide and implement an infection prevention and control program.

✓ Corrected: Aug 30, 2024
Tag 0803 D Jul 24, 2024

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.

✓ Corrected: Aug 6, 2024
Tag 0812 D Jul 24, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Aug 6, 2024
Tag 0690 D May 7, 2024

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: May 29, 2024
Tag 0580 D Jan 5, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Jan 15, 2024
Tag 0755 D Jan 5, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Jan 15, 2024
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2023 25 violations

Tag 0552 D Oct 26, 2023

Ensure that residents are fully informed and understand their health status, care and treatments.

✓ Corrected: Nov 10, 2023
Tag 0580 D Oct 26, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Nov 10, 2023
Tag 0584 D Oct 26, 2023

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.

✓ Corrected: Nov 10, 2023
Tag 0645 E Oct 26, 2023

PASARR screening for Mental disorders or Intellectual Disabilities

✓ Corrected: Nov 10, 2023
Tag 0656 E Oct 26, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 10, 2023
Tag 0686 E Oct 26, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Nov 10, 2023
Tag 0689 D Oct 26, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Nov 10, 2023
Tag 0692 D Oct 26, 2023

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Nov 10, 2023
Tag 0695 E Oct 26, 2023

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Nov 10, 2023
Tag 0711 D Oct 26, 2023

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

✓ Corrected: Nov 10, 2023
Tag 0755 D Oct 26, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Nov 10, 2023
Tag 0758 D Oct 26, 2023

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.

✓ Corrected: Nov 10, 2023
Tag 0761 E Oct 26, 2023

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: Nov 10, 2023
Tag 0812 E Oct 26, 2023

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Nov 10, 2023
Tag 0814 E Oct 26, 2023

Dispose of garbage and refuse properly.

✓ Corrected: Nov 10, 2023
Tag 0880 E Oct 26, 2023

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 10, 2023
Tag 0919 D Oct 26, 2023

Make sure that a working call system is available in each resident's bathroom and bathing area.

✓ Corrected: Nov 10, 2023
Tag 0689 D Oct 5, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Oct 31, 2023
Tag 0550 D Aug 8, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Sep 1, 2023
Tag 0609 D Jun 22, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Jul 1, 2023

2022 17 violations

Tag 0755 D Dec 7, 2022

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Jan 5, 2023
Tag 0758 E Dec 7, 2022

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.

✓ Corrected: Jan 5, 2023
Tag 0760 G Dec 7, 2022

Ensure that residents are free from significant medication errors.

✓ Corrected: Jan 5, 2023
Tag 0550 E Oct 28, 2022

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Nov 24, 2022
Tag 0565 E Oct 28, 2022

Honor the resident's right to organize and participate in resident/family groups in the facility.

✓ Corrected: Nov 24, 2022
Tag 0625 D Oct 28, 2022

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.

✓ Corrected: Nov 24, 2022
Tag 0656 E Oct 28, 2022

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 24, 2022
Tag 0658 D Oct 28, 2022

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Nov 24, 2022
Tag 0676 D Oct 28, 2022

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

✓ Corrected: Nov 24, 2022
Tag 0686 D Oct 28, 2022

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Nov 24, 2022
Tag 0688 E Oct 28, 2022

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.

✓ Corrected: Nov 24, 2022
Tag 0755 D Oct 28, 2022

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Nov 24, 2022
Tag 0806 D Oct 28, 2022

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

✓ Corrected: Nov 24, 2022
Tag 0842 E Oct 28, 2022

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

✓ Corrected: Nov 24, 2022
Tag 0880 E Oct 28, 2022

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 24, 2022
Tag 0755 D Jul 30, 2022

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Sep 9, 2022
Tag 0887 D Feb 25, 2022

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.

✓ Corrected: Apr 20, 2022
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2021 2 violations

Tag 0609 D Nov 30, 2021

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Dec 9, 2021
Tag 0880 D Jul 15, 2021

Provide and implement an infection prevention and control program.

✓ Corrected: Aug 23, 2021

2020 2 violations

Tag 0880 E Oct 29, 2020

Provide and implement an infection prevention and control program.

✓ Corrected: Nov 9, 2020
Tag 0580 D Apr 15, 2020

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Apr 28, 2020
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2019 9 violations

Tag 0558 D Nov 21, 2019

Reasonably accommodate the needs and preferences of each resident.

✓ Corrected: Dec 18, 2019
Tag 0641 D Nov 21, 2019

Ensure each resident receives an accurate assessment.

✓ Corrected: Dec 18, 2019
Tag 0658 D Nov 21, 2019

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Dec 18, 2019
Tag 0693 D Nov 21, 2019

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.

✓ Corrected: Dec 18, 2019
Tag 0755 D Nov 21, 2019

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Dec 18, 2019
Tag 0756 D Nov 21, 2019

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Dec 18, 2019
Tag 0758 D Nov 21, 2019

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.

✓ Corrected: Dec 18, 2019
Tag 0773 D Nov 21, 2019

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

✓ Corrected: Dec 18, 2019
Tag 0923 D Nov 21, 2019

Have enough outside ventilation via a window or mechanical ventilation, or both.

✓ Corrected: Dec 18, 2019

2018 30 violations

Tag 0561 D Nov 30, 2018

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

✓ Corrected: Dec 26, 2018
Tag 0578 E Nov 30, 2018

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.

✓ Corrected: Dec 26, 2018
Tag 0584 D Nov 30, 2018

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.

✓ Corrected: Dec 26, 2018
Tag 0606 D Nov 30, 2018

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

✓ Corrected: Dec 26, 2018
Tag 0607 B Nov 30, 2018

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

✓ Corrected: Dec 26, 2018
Tag 0609 D Nov 30, 2018

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Dec 26, 2018
Tag 0623 D Nov 30, 2018

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Dec 26, 2018
Tag 0636 D Nov 30, 2018

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

✓ Corrected: Dec 26, 2018
Tag 0638 E Nov 30, 2018

Assure that each resident’s assessment is updated at least once every 3 months.

✓ Corrected: Dec 26, 2018
Tag 0641 B Nov 30, 2018

Ensure each resident receives an accurate assessment.

✓ Corrected: Dec 26, 2018
Tag 0679 D Nov 30, 2018

Provide activities to meet all resident's needs.

✓ Corrected: Dec 26, 2018
Tag 0684 D Nov 30, 2018

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

✓ Corrected: Dec 26, 2018
Tag 0686 D Nov 30, 2018

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Dec 26, 2018
Tag 0689 D Nov 30, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Dec 26, 2018
Tag 0690 D Nov 30, 2018

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Dec 26, 2018
Tag 0693 D Nov 30, 2018

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.

✓ Corrected: Dec 26, 2018
Tag 0697 D Nov 30, 2018

Provide safe, appropriate pain management for a resident who requires such services.

✓ Corrected: Dec 26, 2018
Tag 0700 D Nov 30, 2018

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.

✓ Corrected: Dec 26, 2018
Tag 0756 D Nov 30, 2018

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Dec 26, 2018
Tag 0758 D Nov 30, 2018

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.

✓ Corrected: Dec 26, 2018
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2017 19 violations

Tag 0550 D Dec 12, 2017

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Jan 4, 2018
Tag 0584 E Dec 12, 2017

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.

✓ Corrected: Jan 4, 2018
Tag 0623 D Dec 12, 2017

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Jan 4, 2018
Tag 0641 D Dec 12, 2017

Ensure each resident receives an accurate assessment.

✓ Corrected: Jan 4, 2018
Tag 0656 D Dec 12, 2017

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Jan 4, 2018
Tag 0658 D Dec 12, 2017

Ensure services provided by the nursing facility meet professional standards of quality.

✓ Corrected: Jan 4, 2018
Tag 0686 D Dec 12, 2017

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Jan 4, 2018
Tag 0689 D Dec 12, 2017

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jan 4, 2018
Tag 0690 D Dec 12, 2017

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Jan 4, 2018
Tag 0695 E Dec 12, 2017

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Jan 4, 2018
Tag 0698 D Dec 12, 2017

Provide safe, appropriate dialysis care/services for a resident who requires such services.

✓ Corrected: Jan 4, 2018
Tag 0759 E Dec 12, 2017

Ensure medication error rates are not 5 percent or greater.

✓ Corrected: Jan 4, 2018
Tag 0761 D Dec 12, 2017

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: Jan 4, 2018
Tag 0806 D Dec 12, 2017

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

✓ Corrected: Jan 4, 2018
Tag 0812 D Dec 12, 2017

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Jan 4, 2018
Tag 0880 E Dec 12, 2017

Provide and implement an infection prevention and control program.

✓ Corrected: Jan 4, 2018
Tag 0908 D Dec 12, 2017

Keep all essential equipment working safely.

✓ Corrected: Jan 4, 2018
Tag 0923 E Dec 12, 2017

Have enough outside ventilation via a window or mechanical ventilation, or both.

✓ Corrected: Jan 4, 2018
Tag 0500 D Jul 31, 2017

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.

✓ Corrected: Aug 4, 2017
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