Health inspection·April 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of 35 sampled residents (Resident 1), when Resident 1 eloped (left the facility unsupervised without prior authorization) through an unsecured exit gate. This failure decreased the facility's potential to maintain residents' safety and prevent accidents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in November 2024 with a diagnosis of bipolar schizoaffective disorder (causes mood swings that range from the lows of depression to elevated periods of emotional highs and a mental illness that is characterized by disturbances in thought). A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 2/26/25, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 out of 15 with good memory and judgement. During an interview on 4/21/25 at 1:30 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated Resident 1 eloped from the facility on 4/20/25 at approximately 2:30 p.m. when he was outside on the basketball court patio with other residents. LN 1 further stated staff on the patio noticed Resident 1 was missing; a search was conducted, and Resident 1 was not found. During an interview on 4/21/25 at 1:40 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was outside on the basketball court with a group of residents. CNA 1 further stated she was told Resident 1 was missing, so she participated in the facility's search and Resident 1 was not found. During a concurrent observation and interview on 4/21/25 at 1:55 p.m. with LN 1, LN 1 walked out of the facility to the first patio area. The patio area was secured with a keypad and had gates locked with a working alarm speaker box. LN 1 unlocked the gate and exited to the basketball patio. The basketball patio had two exit doors. Both exit doors had non-functioning security keypads, a sign indicating push until alarm sounds door can be open in 15 seconds, and no alarm speaker boxes. Both exit doors were unlocked, opened easily without using the push bar, and led towards the open parking lot area. No audible alarm was heard when doors were opened, and both doors did not automatically and securely close when released. LN 1 confirmed the observations and stated the basketball patio area (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555459 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555459 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gramercy Court 2200 Gramercy Drive Sacramento, CA 95825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)