Health inspection·February 25, 2026

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 observation, interview and record review the facility failed to protect one of four sampled resident's (Resident 4) from abuse when Resident 3 threw a chair at Resident 4 who attempted to deflect the chair and sustained an injury.This failure resulted in slight pain and a minor fracture to the ring finger.Findings:Resident 3 was admitted to the facility in the winter of 2024 with diagnosis which included schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia (hallucinations or delusions) with severe mood swings of mania and sometimes depression).During a review of Resident 3's Minimum Data Set (MDS, an assessment tool), dated 12/10/25, the MDS indicated Resident 4 was alert and oriented, able to make her needs known.During a review of Resident 3's care plan (CP) titled .At risk of becoming physically aggressive towards others.History of harm/assaultive behavior to others, Poor impulse control, fixated delusional thoughts, agitation., revised 12/18/25, the CP indicated Assess and anticipate resident's needs.Intervene before agitation escalates. Resident 4 was admitted to the facility in the winter of 2025 with diagnoses which included schizophrenia (a chronic, severe brain disorder that causes people to lose touch with reality, disrupting how they think, feel, and behave).During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was alert and oriented, able to make her needs known.During a review of Resident 4's CP titled At risk for behavioral disturbances related to Hx [history] of assaultive behavior, schizophrenia, revised 1/15/26, the CP indicated .Provide secure & comfortable environment.During a review of Resident 3's nurses notes (NN), dated 2/4/26, the NN indicated Resident was involved in a behavioral incident in the dining room.Resident stood up, lifted the chair she has been sitting on, and threw it toward another resident [Resident 4].Resident stated she believed the other resident was going to hurt her brother, which prompted her reaction.During a review of Resident 4's social services note (SSN), undated, the SSN indicated, SS spoke with resident regarding and(sic) incident that occurred in the dining room while waiting for smoked (sic) break. Resident stated, I'm not sure (sic) she didn't say anything (sic) she didn't look mad (sic) she just stood up lifted the chair and turned and threw it (sic) I blocked it with my hand.During a review of Resident 4's Radiology Results Report (RRR), dated 2/6/26, the RRR indicated .Soft tissue swelling.Mild.fracture.During an interview on 2/24/26 at 1:13 p.m. with the Social Services Director (SSD) in the conference room about the incident on 2/4/26 which involved Resident 3 and Resident 4, the SSD stated, [Resident 3] has delusions at times and it seems to be family related.During a concurrent observation and interview on 2/24/26 at 1:57 p.m. with Resident 4 in the upper activity room, Resident 4 was observed to have a hard splint from the ring finger to the left elbow wrapped with gauze. She was asked about the incident on 2/4/26. Resident 4 stated, My ring finger got broken It doesn't hurt. It's just good if I stay away from [Resident 3].We were waiting for a smoke break .She stood and threw the chair toward me. I think it was intentional. I just stopped the chair as it came toward me. My hands hit the (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 02/25/2026 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)