Federal inspection record · CMS data as of October 1, 2026
Gem Tcu
716 South Fair Oaks Ave, Pasadena, CA · (626) 737-0560
- Certified beds
- 75
- Residents per day
- 66
- Ownership
- For-Profit
- Chain
- Abraham Bak & Menachem Gastwirth
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- April 1, 1972
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Gem Tcu carries 161.75 inspection points. That is fewer than 16% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
88 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
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.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care24E
- E
Honor each resident's preferences, choices, values and beliefs.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
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.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
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.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary15E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
Dispose of garbage and refuse properly.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- E
Ensure 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.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure 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.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Dispose of garbage and refuse properly.
Resident Rights14E
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
- D
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.
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- E
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor 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.
- E
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- D
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.
Resident Assessment and Care Planning7E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
PASARR screening for Mental disorders or Intellectual Disabilities
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control7E
- E
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Pharmacy Service6E
- E
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.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
Environmental5E
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
- D
Keep all essential equipment working safely.
- B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Nursing and Physician Services4E
- B
Post nurse staffing information every day.
- B
Post nurse staffing information every day.
- E
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Freedom from Abuse, Neglect, and Exploitation4D
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspection history
2025-11-19
22 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2024-11-01
34 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
2023-10-26
32 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 30 min of nursing staff time a day, 35 min of it from a registered nurse.
This home
4 h 30 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 65% of nursing staff and 50% of registered nurses left in the past year, along with 3 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$27,808 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-05-16 | Fine | $27,808 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.6 pts worse | 3.8 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.2 pts worse | 1.7 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.8 pts better | 99.5% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.7 pts better | 0.9% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2 pts better | 5.6% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight5.1 pts worse | 9.2% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.6 pts better | 13.1% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication11.6 pts worse | 23.9% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.7 pts worse | 9.6% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.7 pts worse | 16.9% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.4 pts better | 0.3% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.7 pts better | 0.5% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.2 pts worse | 11.0% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers3.2 pts worse | 7.5% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine1.9 pts worse | 92.7% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.7 pts worse | 11.8% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medicationAbout the same | 1.3% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccineAbout the same | 93.1% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission4.5 pts better | 18.1% | 22.6% | 23.4% |
·
Who owns and runs it
33 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Lehmann, Kenneth | 5% Or Greater Direct Ownership Interest · Individual | 25% | 17 facilities |
| Abak Consulting LLC | Adp Of The SNF · Organization | 0% | 14 facilities |
| Abe And Rachel Bak Family Trust | Adp Of The SNF · Organization | 0% | 10 facilities |
| Ahm Family Holdings LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
| Am Holdco, LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
| Amc Family Holding LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
| Amm Family Holdings LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
| Asm Family Holdings LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
| Atr Family Holdings LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
| Bak, Abraham | Operational/Managerial Control · Individual | 0% | 24 facilities |
| Bak, Abraham | Adp Of The SNF · Individual | 0% | 24 facilities |
| Bak, Rachel | Adp Of The SNF · Individual | 0% | 8 facilities |
| Fair Oaks Propco LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Gastwirth, Menachem | Adp Of The SNF · Individual | 0% | 21 facilities |
| Lehmann, Kenneth | Operational/Managerial Control · Individual | 0% | 17 facilities |
| Lehmann, Kenneth | Adp Of The SNF · Individual | 0% | 17 facilities |
| Levine, Ychail | Direct Ownership Interest · Individual | 0% | 2 facilities |
| Lighthouse United Partners LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Mayer 2012 Trust | Adp Of The SNF · Organization | 0% | 4 facilities |
| Mayer Family 2016 Irrevocable Trust | Adp Of The SNF · Organization | 0% | 2 facilities |
| Mayer, Akiva | Indirect Ownership Interest · Individual | 0% | 4 facilities |
| Mayer, Akiva | Adp Of The SNF · Individual | 0% | 4 facilities |
| Mayer, Helene | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 13 facilities |
| Mayer, Ronald | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 13 facilities |
| Mcp 1 LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Mft 2020 Trust Dated November 12, 2020 | Adp Of The SNF · Organization | 0% | 1 facilities |
| Mgaz Consulting LLC | Adp Of The SNF · Organization | 0% | 14 facilities |
| Montag, Memphis | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Montag, Memphis | Adp Of The SNF · Individual | 0% | 4 facilities |
| Wynstock, Lori | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Wynstock, Lori | Adp Of The SNF · Individual | 0% | 1 facilities |
| Yuz, Alexander | Adp Of The SNF · Individual | 0% | 2 facilities |
| Zm Family Holdings LLC | Direct Ownership Interest · Organization | 0% | 3 facilities |
·
Fire safety
24 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Install corridor and hallway doors that block smoke.
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- E
Install corridor and hallway doors that block smoke.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Install an approved automatic sprinkler system.
Gas, Vacuum, and Electrical Systems4E
- E
Ensure proper usage of power strips and extension cords.
- D
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- D
Meet requirements for the installation and maintenance of electrical systems.
Emergency Preparedness3F
- F
Establish methods for sharing information.
- F
Provide a means of sharing information on occupancy/needs.
- F
Establish emergency prep training and testing.
Miscellaneous2E
- E
Have simulated fire drills held at unexpected times.
- E
Have restrictions on the use of highly flammable decorations.
Egress2D
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Services1E
- E
Have properly installed electrical wiring and gas equipment.
·
Other homes nearby
-
The Bellefontaine Healthcare Center
Pasadena, CA · Links Healthcare Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 57 min
- Fines
- $14,414
-
The Californian Pasadena Healthcare
Pasadena, CA · Abraham Bak & Menachem Gastwirth
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 5 h 2 min
- Fines
- $0
-
South Pasadena Care Center
South Pasadena, CA
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 29 min
- Fines
- $0