A list of the most recent deficiencies for Gem Transitional. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-05 | 2024-01-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-05 | 2024-01-15 | Y |
| Establish methods for sharing information. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-30 | 2023-11-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-10-26 | 2023-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-26 | 2023-11-10 | N |
| 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. | Health | 2023-10-26 | 2023-11-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-26 | 2023-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-26 | 2023-11-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-26 | 2023-11-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-10-26 | 2023-11-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-26 | 2023-11-10 | N |
| 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. | Health | 2023-10-26 | 2023-11-10 | N |
| 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. | Health | 2023-10-26 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-10 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-26 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-26 | 2023-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-08 | 2023-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-06 | 2023-07-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-22 | 2023-07-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-12 | 2023-06-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-12 | 2023-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-05-05 | Y |
| 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. | Health | 2023-03-03 | 2023-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-07 | 2023-01-05 | Y |
| 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. | Health | 2022-12-07 | 2023-01-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-07 | 2023-01-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-28 | 2022-11-24 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-28 | 2022-11-24 | N |
| 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. | Health | 2022-10-28 | 2022-11-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-28 | 2022-11-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-28 | 2022-11-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-28 | 2022-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-28 | 2022-11-24 | N |
| 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. | Health | 2022-10-28 | 2022-11-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-28 | 2022-11-24 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-28 | 2022-11-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-28 | 2022-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-28 | 2022-11-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-27 | 2022-11-14 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-10-27 | 2022-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-27 | 2022-11-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-30 | 2022-09-09 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-03-11 | 2022-06-14 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-11 | 2022-06-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-11 | 2022-06-14 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-03-11 | 2022-06-14 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-11 | 2022-06-14 | Y |
| 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. | Health | 2022-02-25 | 2022-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-30 | 2021-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-21 | 2019-12-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-21 | 2019-12-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-21 | 2019-12-18 | N |
| 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. | Health | 2019-11-21 | 2019-12-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-21 | 2019-12-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-21 | 2019-12-18 | N |
| 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. | Health | 2019-11-21 | 2019-12-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-11-21 | 2019-12-18 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-11-21 | 2019-12-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-21 | 2019-12-18 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-11-21 | 2019-12-18 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-11-21 | 2019-12-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-21 | 2019-12-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-21 | 2019-12-18 | N |
