Gem City Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Gem City Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 13, 2023

  Based on medical record review, staff interview, physician interview, and review of facility policy, the facility failed to initiate wound treatments, assess wounds weekly, and consult wound care as ordered. This resulted in actual harm to Resident #3 when a facility acquired wound increased in size. This affected Resident #3 of three reviewed. The census was two. Findings include: Review of Resident #3's closed medical record revealed an admitted [DATE]. Diagnoses listed included hypertension, acute and chronic respiratory failure, seizures, hydrocephalus, dysphagia, schizophrenia, type II diabetes mellitus, and respiratory ventilator dependence. […]

• Actual harm, isolatedF686Mar 13, 2023

  Based on medical record review, staff and physician interviews, review of facility policy, and review National Pressure Injury Advisory Panel (NPIAP) information, the facility failed to initiate pressure ulcer treatments, complete pressure ulcer treatments as ordered, assess pressure ulcers weekly, and consult wound care as ordered. This resulted in Actual Harm when Resident #03's facility acquired pressure ulcers to the right and left rear thighs increased in size. This affected one (#03) of three residents reviewed for skin breakdown. The census was two. Findings include: Review of Resident #03's closed medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF880May 21, 2026

  Based on record review, observation, interview, and facility policy review the facility failed to wear proper Personal Protective Equipment (PPE) while providing personal care. This affected one Resident #02 out of 23 residents requiring PPE for Enhanced Barrier Precautions (EBP). the faciity also failed to ensure clean linens were stored appropriately. This had the potential to affect all residents. The facility census was 33.Findings include: 1. A chart review revealed Resident #02 was admitted on [DATE] with diagnosis including hemiplegia/hemiparesis, dysphagia, diabetes, and depression. […]

• No harm, potential for more than minimal, widespreadF584Jul 1, 2025

  Based on observation, resident and staff interview, and record review, the facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded 95 degrees Fahrenheit (F) in resident rooms. This affected all ten residents (#01, #02, #03, #04, #05, #06, #07, #108, #109 and #158) residing in the facility. The facility census was 10. Findings include: Interview with Resident #04 on 06/29/25 at 9:50 A.M. revealed it was hot in her room. […]

• No harm, potential for more than minimal, widespreadF921Jun 3, 2022

  Based on observations, staff and resident interviews, record review, and policy review the facility failed to provide a facility environment with temperatures below 81 degrees Fahrenheit. This had the potential to affect every resident in the facility. The facility census was 45. Findings include: Interview on 05/31/22 at 9:10 A.M. with the Administrator revealed the facility did have a problem with higher air temperatures within the facility over the past week. The Administrator confirmed that the facility might be hot or cold depending on the weather outside. The facility had contracted the help of a local Heating and Air conditioning company many times in the month of May 2022. […]