Health inspection·December 5, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation, interview, and record review on 12/4/25 at 8:55 a.m. with the Environmental Services Specialist (ESS) and the Maintenance Assistant (MA) in Resident 62's and Resident 120's room, the in-room thermometer displayed 67 degrees F. The MA used hand-held thermometer to measure several surfaces in the room: the wall measured 68.5 degrees F and the ceiling measured 69 degrees F. The ESS stated that temperature issues were reported to the maintenance staff via the communication logbook, and the issues get addressed in a timely manner. The ESS walked over to the nurse's station and showed the logbook. The logbook sheet for December of 2025 indicated that Resident 62's and Resident 120's room was reported to be too cold on 12/1/25 and too hot on 12/3/25. The ESS confirmed that there were no room specific temperature monitoring and documentation following attempted temperature adjustments for the room on 12/1/25 and 12/3/25. The ESS further stated that the facility should maintain a temperature between 71 and 81 degrees F. 2. During a review of Resident 61's AR, dated 12/5/25, the AR indicated, Resident 61 was admitted to the facility in May of 2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and needed for assistance with personal care. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had a BIMS score of 10 out of 15 suggestive of moderate cognitive impairment. During a concurrent observation and interview on 12/2/25 at 8:30 a.m. with Resident 61, Resident 61 walked from his room into the hallway with two blankets over his shoulders. Resident 61 stated he was very uncomfortable because of the temperature of the facility and his room was cold. During an interview on 12/4/25 at 8:49 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated when a resident was uncomfortable from a cold room, she expected maintenance to follow up to make sure the resident's room was at a comfortable temperature. During a concurrent observation, interview, and record review on 12/5/25 at 8:30 a.m. with the ESS in Resident 61's room, the ESS used a hand-held thermometer to measure the temperature of Resident 61's room. Resident 61's room measured 64.5 degrees F. The ESS stated the residents' rooms should be set at the comfortable level requested by the resident, and the facility should maintain a temperature between 71 and 81 degrees F for the comfort of the residents. During a concurrent observation and interview in Resident 61's room, on 12/5/25 at 8:40 a.m. with Resident 61, Resident 61 was observed with hands in his pockets, wearing a thick sweater, long sleeve shirt and long pants on. Resident 61 stated he was uncomfortable and stated, I have lived on the streets for years and I am used to the cold, but here [his room and facility] is very cold. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.comfortable and safe temperatures (71 degrees F - 81 degrees F). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555459 If continuation sheet Page 2 of 7 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 12/05/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure accurate handling, storage, disposal, and documentation of controlled medications (medications with high potential for abuse or addiction) were provided for residents in a census of 101, when:1. There was no efficient system in place to accurately document and secure disposed controlled medications when two stored bags containing controlled substances were easily retrievable; and 2. There was no accurate documentation on controlled medication for Resident 98, when the administration date was missing, and two bottles of controlled substances were documented on only one controlled drug record with a discrepancy on the remaining quantity of the medication.These failures had the potential for drug diversion (theft for personal use or illegal sale), and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.1.During a concurrent observation and interview on 12/2/25 at 8:50 a.m. with Licensed Nurse (LN) 3 at the facility medication cart C1 (C1), LN 3 confirmed there was a bag that contained multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of C1. LN 3 stated the half pills inside the bags were considered disposed of inside the cart into the bag after being verified by two nurses. During a concurrent observation and interview on 12/02/25 4:16 p.m. with LN 4 at the facility medication cart W1 (W1), LN 4 confirmed there was a bag that contained multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of W1. LN 4 stated the expectation was for nursing staff to make a copy of the controlled drug record, place the controlled drug into a small plastic bag uncrushed and staple it to a copy of the controlled drug record. LN 4 further stated she was expected to sign the controlled drug record that contained the stapled uncrushed controlled drug with two nurses, fold it up, then place it inside a larger plastic bag with the remaining discontinued controlled drugs until the DON (Director of Nursing) picked up to destroy the controlled substances with the pharmacist. LN 4 confirmed there was no controlled drug destruction at the medication carts, and no controlled drugs were placed in any unretrievable medication bins. During a concurrent observation and interview on 12/4/25 at 8:49 a.m. with LN 2 at W1, LN 2 confirmed there was a bag that held multiple uncrushed controlled drugs within small plastic bags stapled to folded control drug records located inside the drawer of W1. LN 2 confirmed there were uncrushed controlled drugs held in drawer for over a week. LN 2 stated the expectation was for staff to keep discontinued uncrushed controlled medications that were half pills inside the small plastic bags then stapled to a folded controlled paper which was placed in a larger bag with other held controlled substances and picked up weekly by the DON. LN 2 stated the reason to properly destroy controlled substances was for the safety of residents and to make sure diversion was avoided, and that best practice to immediately dispose of narcotics so they were not easily accessible or retrievable. During an interview on 12/4/25 at 1:40 p.m. with the DON, the DON stated the expectation was for a discontinued controlled substance to not be stored for no more than three days and that one month was not acceptable. The DON stated, It does not always happen how it was supposed to. The DON stated If staff destroyed controlled substances on the cart the medication was placed in plastic after crushing, attached to the count sheet and turned to the DON. The DON stated she expected staff to bring the count sheets and stored controlled substances to the office or be destroyed in the medication room destruction bin, so controlled drugs were safe, unretrievable in containers to avoid diversion. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated 2001, the P&P indicated, 6.when a resident.receives a partial tablet (or it is not given) the medication is destroyed.The facility complies with all laws, regulations, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555459 If continuation sheet Page 3 of 7 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 12/05/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances: 9. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. 2. During a review of Resident 98's admission Record (AR), dated 12/5/25, the AR indicated Resident 98 was readmitted to the facility Fall of 2025 with diagnosis which included malignant kidney neoplasm (kidney cancer), palliative care (specialized medical care that helps people managing symptoms like pain), and rheumatoid arthritis (disease that causes pain and stiffness in hands, wrist and joints). During a review of Resident 98's Order Summary Report [OSR], dated 12/5/25, the OSR indicated, Hydromorphone [pain medication] Give 3 ml by mouth every 3 hours for Pain management. During a review of Resident 98's Shipping Manifest [controlled substance delivery receipt form), dated 11/30/25, the manifest indicated a 60 mL of hydromorphone 5 mg/mL was received for Resident 98. During a review of Resident 98's Medication Administration Record (MAR) for November 2025 and December 2025, the MAR indicated a total of 19 ml of hydromorphone remained after the medication administration. During a concurrent interview and record review on 12/4/25 at 4:22 p.m. with the DON, Resident 98's Controlled Drug Record Liquids, multidose (CDR), dated 11/30/25, was reviewed. Resident 98's CDR indicated one missed administration time for a 2 ml administration of hydromorphone on 12/2/25 and that 19 mL of hydromorphone remained to be wasted. The DON held Resident 98's bottle of hydromorphone at eye level and confirmed Resident 98's bottle of hydromorphone contained 30 mL of hydromorphone instead of 19 ml. The DON stated controlled drug records were expected to be completed and should be easily read and reconcilable. The DON acknowledged the discrepancy and stated she expected the remaining medication volume in the bottle to match the count sheet volume for resident safety and to avoid drug diversion. During a review of the facility's policy and procedure titled, Controlled Substances, date 2001, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) .Dispensing and Reconciling Controlled Substances: 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count .Handling Controlled Substances 3. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion . Handling Controlled Substances. This record contains: j. time of administration. Event ID: Facility ID: 555459 If continuation sheet Page 4 of 7 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 12/05/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food storage and preparation, in accordance with professional standards for food service safety, was provided to residents in a census of 101, when: 1. Floors, rolling racks, equipment, pots/pans, grill/stove panel, refrigerator doors, water pitcher preparation area, garbage cans, can opener, and towels were found unclean and unsanitary; 2. Food, and staff's personal food and drink, items were found in refrigerators and in the dry storage room, opened, not labeled, not securely covered, dented, and expired; and 3. Kitchen staff did not know how to explain or demonstrate the proper procedures for testing sanitizing solutions, and expired test strips were being used. These failures had the potential to cause food-borne illnesses in a vulnerable population. 1. During a concurrent observation and interview on 12/2/25 beginning at 8 a.m. in the kitchen with the Certified Dietary Manager (CDM), the CDM confirmed the kitchen area and equipment were uncleaned and unsanitary. The CDM acknowledged and verified the following:a. The kitchen floors had food stains and debris in corners; b. The grill stove panel, rolling cart racks with holding trays, and refrigerator doors were smeared with a white substance; c. The refrigerator doors were smeared with a black particle substance; d. A blue plastic garbage can, with food debris around the bottom and white brown streaks on the outside of can, near the food preparation area; e. Pots and pans, with food crumbs and brown white stains, on a fixed rack near the grill oven; f. A rolling white container with no lid, with Kitchen Rags written in black marker on the side, was found over filled with towels and a mop head that was grease stained and smelled musty, in the dry food storage room; g. The stainless-steel preparation area, for coffee, tea and water pitchers, was found with dried white streaks and brown stains leading to floor, and the shelf area underneath had a large dried dark brown stain; andh. The dishwasher was found with thick residue along panel near the motor mechanism. The CDM stated there was no weekly cleaning log sheet identifying staff duties. The CDM provided an In Service Compliance Training Record, for towels, staff signatures dated 10/2025, with topic: yellow dirty towel bin must now be stored in dry storage. No exception. The CDM stated expectations were for staff to keep kitchen areas, and all items used, clean and in sanitary conditions. The CDM stated it was important to prevent food-borne illnesses and avoid cross contamination. During a concurrent observation and interview on 12/4/25 at 9:15 a.m. in kitchen with the CDM, the CDM confirmed the can opener was found with chipped metal shavings on tip, and dried dark food particles with strands of hair on shaft holder. The CDM stated the expectation was for the can opener to be kept clean and free from defect. The CDM stated it was important to prevent metal flakes from getting into food, which could cause harm to residents. During a review of the facility's policy and procedure (P&P) titled, General Sanitation of Kitchen, dated 5/2017, the P&P stipulated, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During a review of the facility's P&P titled, Kitchen Cloths, dated 2017, the P&P stipulated, Kitchen cloths will be clean.2.soiled cloths will be sent to the laundry and replaced with clean cloths.3. Recyclable kitchen cloths will be laundered separately.They will be dried, folded . During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, revised 8/2019, the P&P stipulated, .13. Mop heads.will be decontaminated regularly.dried.daily. During a review of the facility's P&P titled, Sanitization, revised 11/2022, the P&P stipulated, .2. All.equipment are kept clean, maintained in good repair and are free from.corrosions. 2. During a concurrent observation and interview on 12/2/25 beginning at 8 a.m. in the kitchen with the CDM, the CDM confirmed food items were not properly stored and labeled. The CDM verified and acknowledged the following:a. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555459 If continuation sheet Page 5 of 7 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 12/05/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food item of potato salad was found, in a clear plastic container, loosely covered with plastic wrap, with no open date label, and an expired date 11/21/25 written on a label in black marker, in the walk-in refrigerator;b. Three staffs' personal drinks were found in the residents' refrigerator on the second shelf; c. A caramel sauce bottle was found, opened with no date with white sticky substance leaked from top of the opening, on a shelf in the dry food storage room; d. An unidentified food item was found moldy, wrapped in clear plastic and foil wrap, on an opened box identified as tartar sauce, on a shelf in the dry food storage room, next to staff standing lockers for personal items; ande. A dented zero sugar cola can was found on bottom shelf of residents' refrigerator. The CDM stated the unidentified food item belonged to one of the kitchen staff. The CDM indicated the expectations for staff, were: to throw away expired food items; to use the bottom shelf of residents' refrigerator, or to use staff refrigerators on the nursing units, for personal food and drink items; not to eat personal food items in the dry food storage room; to label food items when opened with a date and kept clean. The CDM stated that it was important to prevent food-borne illnesses, cross contamination, and pests. During a review of the facility's P&P titled, Dry Storage Areas, dated 2017, the P&P stipulated, Dry storage areas will be kept in a condition which protects stored foods from infestation.4. Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. During a review of the facility's P&P titled, Food Receiving and Storage, dated 2001, the P&P stipulated, Dry Food Storage.7. Foods may not be stored: a. in locker rooms.Refrigerated/Frozen Storage 1. All foods stored in the refrigerator.are covered, labeled and dated ( use by date). A policy for kitchen staff personal food items was requested from the CDM but was unable to provide. 3. During a concurrent observation and interview on 12/2/25 at 9:10 a.m. in the kitchen with Dietary Aide 1 (DA 1), DA 1 was asked to explain and demonstrate how to test the sanitizer solution during final rinse of the dishwasher machine. DA 1 opened the left side door of the dishwasher and pulled the clean dishes rack onto the platform. DA 1 removed a test strip from a chlorine test paper bottle, swiped the strip across a clean, wet plate cover, held it next to the test strip bottle, and stated the result did not read 50-100 parts per million (ppm, a unit of concentration or ratio measuring contaminants or elements in water). DA 1 acknowledged the test strip yellow color result was not the recommended manufacturer's blue color. DA 1 requested the assistance of DA 2 to help explain the differences in color results. DA 2 and the CDM retrieved, and used, a different company's test strip, manufactured to test quaternary (QUAT) solution (a disinfectant cleaner and deodorizer that is effective against certain germs), which did not result in the 100 ppm being documented by staff on the Temperature/Sanitizer Record sheet. The kitchen staff confirmed both chlorine test paper bottles had an expiration date of 09/25. the CDM said staff had not had return demonstration education on how to test for dishwasher chlorine sanitizing solution, or for QUAT solution. The CDM stated it was important for staff to know how to test sanitizing solutions to ensure proper contact of solution on dishes and surfaces to prevent food-borne illnesses. During a concurrent observation and interview on 12/3/25 at 9 a.m. in kitchen with the [NAME] and the CDM, the [NAME] was asked to explain and demonstrate how to test the QUAT sanitizer solution. The [NAME] indicated there was no QUAT solution test form to document the results. The [NAME] stated the QUAT solution in the red bucket was changed every two hours if dirty. The [NAME] acknowledged it was important to maintain solution within range to protect and keep the residents safe. The CDM confirmed there was no form to document QUAT test results. The CDM stated it was important staff had a QUAT solution test result form to ensure solution was maintained within range to prevent cross contamination. During an interview on 12/5/25 at 7:30 a.m. with the Administrator (ADM) and the Administrator-in-Training (AIT), the ADM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555459 If continuation sheet Page 6 of 7 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 12/05/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete indicated his expectation was for kitchen staff to maintain cleanliness, to follow protocols, to prepare food with correct temperatures and residents' preferences. The ADM stated kitchen protocols were important to avoid food-borne illnesses in a vulnerable population. During a review of the facility's P&P titled, General Sanitation of Kitchen, dated 5/2017, the P&P stipulated, .4. Method and materials.to be used for.sanitizing will be written for each task.5. Employees will be trained on how to perform cleaning tasks. During a review of the FDA Food Code 2022, the food code indicated, Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.The hazards associated with the particular foods that are prepared, stored, or served.The type of operation including the methods and extent of food storage, preparation, and service.The number of people served.Whether the population served is highly susceptible population. Event ID: Facility ID: 555459 If continuation sheet Page 7 of 7