ElderGrade

Inspection citations at Gem Tcu

87 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 3 0
2025 39 2
2024 26 0
2023 19 0
E May 6, 2026 Tag F0919 Complaint investigation Corrected May 2026

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

D May 5, 2026 Tag F0689 Complaint investigation Corrected May 2026

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D May 5, 2026 Tag F0657 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D December 17, 2025 Tag F0693 Complaint investigation Corrected Jan 2026

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

B November 19, 2025 Tag F0912 Corrected Dec 2025

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

No actual harm, minimal potential

B November 19, 2025 Tag F0732 Corrected Dec 2025

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D November 19, 2025 Tag F0908 Corrected Dec 2025

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0814 Corrected Dec 2025

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0806 Corrected Dec 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0698 Corrected Dec 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0689 Corrected Dec 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0686 Corrected Dec 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0584 Corrected Dec 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0571 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0558 Corrected Dec 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

D November 19, 2025 Tag F0550 Corrected Dec 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E November 19, 2025 Tag F0880 Corrected Dec 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E November 19, 2025 Tag F0813 Corrected Dec 2025

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

No actual harm, potential for more than minimal harm

E November 19, 2025 Tag F0812 Corrected Dec 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E November 19, 2025 Tag F0645 Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

E August 5, 2025 Tag F0812 Complaint investigation Corrected Aug 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D May 17, 2025 Tag F0627 Complaint investigation Corrected Jun 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

G May 16, 2025 Tag F0689 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

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

Actual harm to a resident

J May 16, 2025 Tag F0742 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

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.

Immediate jeopardy to resident health or safety

E May 8, 2025 Tag F0882 Complaint investigation Corrected May 2025

Infection Control Deficiencies

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

No actual harm, potential for more than minimal harm

E May 8, 2025 Tag F0881 Complaint investigation Corrected May 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D May 7, 2025 Tag F0607 Complaint investigation Corrected May 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D May 3, 2025 Tag F0806 Complaint investigation Corrected May 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D May 3, 2025 Tag F0609 Complaint investigation Corrected May 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D April 28, 2025 Tag F0806 Complaint investigation Corrected May 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D April 28, 2025 Tag F0689 Complaint investigation Corrected May 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D April 1, 2025 Tag F0756 Complaint investigation Corrected Apr 2025

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D April 1, 2025 Tag F0689 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E April 1, 2025 Tag F0758 Complaint investigation Corrected Apr 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 20, 2025 Tag F0686 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D February 25, 2025 Tag F0657 Complaint investigation Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D February 25, 2025 Tag F0609 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D January 29, 2025 Tag F0684 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E January 13, 2025 Tag F0812 Complaint investigation Corrected Jan 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

E January 13, 2025 Tag F0804 Complaint investigation Corrected Jan 2025

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.