Health inspection·February 5, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for four of 11 sampled residents (Resident 1, Resident 4, Resident 5, and Resident 7), when:1. Resident 2 slapped Resident 1 in the back of the head; 2. Resident 3 hit Resident 4 in the face;3. Resident 4 slapped Resident 5 in the face; and4. Resident 6 pushed Resident 7.This failure caused Resident 1 to feel upset, Resident 4 to feel afraid, Resident 5 to have a cut lip, and Resident 7 to have leg pain. Findings:1.Resident 1 was admitted to the facility early 2024 with diagnosis which included Schizophrenia (a chronic, severe mental disorder that affects how a person thinks, feels, and behaves), major depression, and anxiety disorder.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 1/26, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 10/15 which indicated moderate cognitive impairment.Resident 2 was admitted to the facility early 2024 with diagnosis which included Schizophrenia and memory loss.During a review of Resident 2's MDS dated 11/25, the MDS showed a BIMS score of 3/15 which indicated severe cognitive impairment.During a review of Resident 1's Progress Notes (PN) dated 1/19/26, the PN indicated, On 01/19/2026 at approximately 0630 [6:30 a.m.] CNA [Certified Nursing Assistant] witnessed [Resident 2] open handedly slap [Resident 1] on the back of his head.During an interview on 2/4/26 at 2:06 p.m. with Resident 1, Resident 1 stated he was smacked on the back of the head by another resident and the incident upset him.During an interview on 2/4/16 at 2:16 p.m. with CNA 1, CNA 1 stated she witnessed Resident 2 open hand hit Resident 1 on the back of the head.2. Resident 3 admitted to the facility in late 2025 with diagnosis which included Schizophrenia.During a review of Resident 3's MDS dated 12/25, the MDS showed a BIMS score of 13/15 which indicated intact cognition.Resident 4 was admitted to the facility in late 2025 with diagnosis which included Schizophrenia, and need for assistance with personal care.During a review of Resident 4's MDS dated 1/26, the MDS showed a BIMS score of 12/15 which indicated moderately impaired cognition.During a review of Resident 3‘s PN dated 1/15/26, the PN indicated, At approximately 1915 [7:15 p.m.], [Resident 3] was observed by a CNA striking his roommate [Resident 4].[Resident 3] appeared highly psychotic, was unable to follow directions, and displayed aggressive behavior toward staff.During an interview on 2/5/26 at 1:20 p.m. with Resident 4, Resident 4 stated he was in bed and his roommate [Resident 4], started punching me in the face. Resident 4 stated he felt scared after the incident.During an interview on 2/5/26 at 3:11 p.m. with CNA 2, CNA 2 stated he saw Resident 3 lying in bed and trying to defend himself from Resident 4, I saw a few punches.3. Resident 5 was admitted to the facility in late 2025 with diagnosis which included Schizophrenia and need for assistance with personal care.During a review of Resident 5's MDS dated 12/25, the MDS showed a BIMS score of 13/15 which indicated intact cognition.During a review of Resident 5's PN dated 1/18/26, the PN indicated, At approximately 1243 [12:43 p.m.], [Resident 5] entered the room of [Resident 4].[Resident 4] struck [Resident 5] in the face.A mild tear and slight bleeding was (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 02/05/2026 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)