Gem Tcu

In the surveyor’s words

From the most serious findings on record at Gem Tcu, in the surveyor’s own words.

• Immediate jeopardy, isolatedF742May 16, 2025

  Based on observation, interview, and record review the facility to provide treatment and services to attain the highest practicable mental and psychosocial well- being of one of two sampled residents (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) anxiety (a feeling of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life) and who was identified as being danger to self and others (DTSO- the probability that a person will inflict serious physical injury upon the person or another person in the near future) on 4/28/2025 by failing to: 1. […]

• Actual harm, isolatedF689May 16, 2025

  Based on observation, interview and record review, the facility failed to provide a safe environment for one (1) of three (3) sample residents by failing to ensure Resident 1 did not possess one bottle of alcoholic beverage and eight (8) medication bottles from Pharmacy 2 (outside pharmacy) labeled with Resident 1's name while the resident is residing in the facility in accordance with the facility's policy titled Restricted Item /Contraband. As a result of noncompliance, on 5/12/2025 at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). […]

• Actual harm, isolatedF760Dec 7, 2022

  Cross reference F755 and F758 Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free of any significant medication error due to missed and incorrect doses of prescribed psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications. This deficient practice resulted in Resident 1 being transferred to the General Acute Care Hospital (GACH) due to exhibiting aggressive behavior and being a danger to self and others such as attempting to kick staff, cursing (use of offensive or impolite language), locking himself in the bathroom, and stating if he wanted to hurt himself, he would do it without telling staff. […]

• No harm, potential for more than minimal, patternF675Jul 18, 2026

  Based on observation, interview and record review, the facility failed to ensure resident rooms were at a comfortable temperature for three (3) of 3 sampled residents (Resident 1, Resident 2 and Resident 3) by failing to ensure the facility's Heating, Ventilation and Air Conditioning (HVAC, a climate control system that keeps indoor areas at a comfortable temperature) was in good repair.This deficient practice had the potential to result in Residents 1, 2 and 3 feeling uncomfortably hot and negatively affect their quality of life. Findings:a). […]

• No harm, potential for more than minimal, patternF919May 6, 2026

  Based on observation, interview, and record review, the facility failed to provide a functional call light for two (2) of three (3) sampled residents (Residents 2 and 3) in accordance with the facility's policy and procedure (P&P) titled Call System (an emergency, nurse, or service-oriented communication setup that allows users to push a button to alert staff or caregivers), Resident. These failures had the potential to put Residents 2 and 3 at risk of experiencing delays in receiving assistance from facility staff, which could lead to an accident or injury.Findings: 1.During a review of Resident 2 's admission Record, it indicated, the resident was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (a disease that occurs when there is a problem in the… […]