Nursing homeActive
Gem Tcu
716 South Fair Oaks Ave, Pasadena, CA 91105626737056075 certified beds · 66 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
29
since 2023
Deficiencies
87
● 3● 82● 2
Penalties · 3 yrs
$27,808
1 fine
Last survey
2026-05-06
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 2
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-05-06 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-05-05 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-12-17 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-11-19 | Standard | 2140 | CMS-2567 (Care Compare) | — |
| 2025-08-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-17 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-16 | Complaint | 002 | CMS-2567 (Care Compare) | — |
| 2025-05-08 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-05-07 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-03 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-04-28 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-04-01 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-03-20 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-02-25 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-01-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-13 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-01-07 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-11-01 | Standard | 1110 | CMS-2567 (Care Compare) | — |
| 2024-09-25 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-09-23 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-09-18 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-28 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-08-21 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-07-24 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-05-07 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-01-05 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-10-26 | Standard | 0170 | CMS-2567 (Care Compare) | — |
| 2023-10-05 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-08-08 | Complaint | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-05-29Record 055341-20260506-F919
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-29Record 055341-20260505-F657
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-29Record 055341-20260505-F689
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-15Record 055341-20251217-F693
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F558
F571Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F571
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F584
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F645
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F698
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F812
F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F813
F814Dispose of garbage and refuse properly.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F814
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F880
F908Keep all essential equipment working safely.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-12Record 055341-20251119-F908
F732Post nurse staffing information every day.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2025-12-12Record 055341-20251119-F732
F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Scope/severity BPaperwork
Environment
Pattern; potential for minimal harm.Corrected 2025-12-12Record 055341-20251119-F912
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-08Record 055341-20250805-F812
F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-12Record 055341-20250517-F627
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-06-11Record 055341-20250516-F689
F742Provide 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.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-06-11Record 055341-20250516-F742
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-11Record 055341-20250508-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-11Record 055341-20250508-F882
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-11Record 055341-20250507-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-11Record 055341-20250503-F609
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-11Record 055341-20250503-F806
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-09Record 055341-20250428-F689
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-09Record 055341-20250428-F806
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-25Record 055341-20250401-F689
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-25Record 055341-20250401-F756
F758Implement 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-25Record 055341-20250401-F758
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-08Record 055341-20250320-F686
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-21Record 055341-20250225-F609
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-21Record 055341-20250225-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-20Record 055341-20250129-F684
F803Ensure 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.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-31Record 055341-20250113-F803
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-31Record 055341-20250113-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-31Record 055341-20250113-F812
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-01Record 055341-20250107-F689
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F558
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F578
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F600
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F676
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F689
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F695
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F698
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F880
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-01Record 055341-20241101-F925
F732Post nurse staffing information every day.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2024-12-01Record 055341-20241101-F732
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-18Record 055341-20240925-F688
F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-18Record 055341-20240925-F712
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-18Record 055341-20240925-F880
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-04Record 055341-20240923-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-04Record 055341-20240923-F684
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-02Record 055341-20240918-F658
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-19Record 055341-20240828-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-19Record 055341-20240828-F558
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-30Record 055341-20240821-F880
F803Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 055341-20240724-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-06Record 055341-20240724-F812
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-29Record 055341-20240507-F690
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-15Record 055341-20240105-F580
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-15Record 055341-20240105-F755
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F552
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F580
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F584
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F645
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F656
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F695
F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F711
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F755
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F758
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F812
F814Dispose of garbage and refuse properly.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F814
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F880
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-10Record 055341-20231026-F919
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-31Record 055341-20231005-F689
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-01Record 055341-20230808-F550
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-05-16 | Civil money penalty | $27,808 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.51
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day4.47
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours3.95
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover60%
Facility
California
National
California 37% · National 46%
Registered nurse turnover50%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 6.0% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.4% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 21.1% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.5% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 19.1% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 11.4% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 12.6% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Lehmann, Kenneth Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 25% | — | — |
| Bak, Abraham Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lehmann, Kenneth Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Montag, Memphis Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Wynstock, Lori Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Abak Consulting LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Abe And Rachel Bak Family Trust Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ahm Family Holdings LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Am Holdco, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Amc Family Holding LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Amm Family Holdings LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Asm Family Holdings LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Atr Family Holdings LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Bak, Abraham Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Bak, Rachel Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fair Oaks Propco LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Gastwirth, Menachem Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Lehmann, Kenneth Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Levine, Ychail Individual | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Lighthouse United Partners LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mayer 2012 Trust Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mayer Family 2016 Irrevocable Trust Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mayer, Akiva Individual | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
| Mayer, Akiva Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mayer, Helene Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mayer, Ronald Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mcp 1 LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mft 2020 Trust Dated November 12, 2020 Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Mgaz Consulting LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Montag, Memphis Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Wynstock, Lori Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Yuz, Alexander Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Zm Family Holdings LLC Organization | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE | — | — |
Part of a chain
Abraham Bak & Menachem Gastwirth — 18 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for Los Angeles.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| The Californian Pasadena Healthcare Pasadena | 0.2 mi | 2026-05-19 | 2531 |
| The Bellefontaine Healthcare Center Pasadena | 0.2 mi | 2026-06-05 | 1561 |
| South Pasadena Care Center South Pasadena | 1.4 mi | 2026-06-18 | 1530 |
| Villa Gardens Health Care Unit Pasadena | 1.8 mi | 2025-12-05 | 0290 |
| Pasadena Grove Health Center Pasadena | 2.6 mi | 2026-06-23 | 5701 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |