Health inspection·May 28, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1 and hitting Resident 1's head into a wall which resulted in Resident 1 sustaining a skin tear. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: Review of Resident's 1 admission Record indicated Resident 1 was admitted [DATE] with diagnoses including schizoaffective disorder, bipolar type (a mental illness that is characterized by disturbances in thought and mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/14/25, indicated Resident 1 was cognitively intact. Review of facility dcoument titled Health Status Note, for Resident 1 dated 5/18/25, indicated, Resident [1] was assaulted by another resident [2] attempting to break up a fight . Review of Interdisciplinary Team (IDT) Note, dated 5/19/25, indicated, on 5/17/25, resident [1] was assaulted by another resident [2] when attempting to break up a fight. Resident [1] stated . [Resident 2] was hitting the staff and holding her down. The other staff wasn't doing anything, so I [Resident 1] got up to help her . we started fighting and he [Resident 2] hit my head against the wall. upon assessment resident [1] was noted with a bump to his head. Resident [1] also sustained a skin care tear on his right elbow with minimal bleeding resident [1] was transferred to UCD . due to complaints of headaches, nausea, and dizziness . Review of Resident 2's admission Record indicated Resident 2 was admitted [DATE] with diagnoses including Schizophrenia, Unspecified (a mental illness that is characterized by disturbances in thought) and Depression, unspecified (a mental illness low self esteem and loss of interest in normally enjoyed activities). Review of Resident 2's MDS, dated [DATE] indicated Resident 2 had severely impaired cognition. Review of facility dcoument titled Health Status Note, for Resident 2 dated 5/18/25, indicated, Resident [2] assualt staff and resident [1] . (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 05/28/2025 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)