Gramercy Court
Inspection Findings
F-Tag F0600
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 the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 2 pushed Resident 1 which caused a fall to the floor. This failure resulted in an injury to Resident 1's left leg.Findings:Resident 1 was admitted to the facility in mid-2025 with diagnosis which included anxiety disorder, dementia, history of falls, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/16/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 14/15 which indicated intact cognition.Resident 2 was admitted to the facility in late 2024 with diagnosis which included anxiety disorder, intellectual disabilities, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 2's MDS dated [DATE REDACTED], the MDS showed a BIMS score of 12/15 which indicated moderate cognitive impairment.During a review of Resident 1's Progress Note (PN) Type: Change in Condition, dated 8/31/25 at 7:25 p.m. the PN indicated, At approximately 1:15 PM [Resident 1] was observed walking in the hallway.[Resident 2] who was seated suddenly stood up without warning and pushed the (sic) [Resident 1], [Resident 1] fell onto her left side.she [Resident 1] was noted to have limited mobility in the left leg and hip.received result of the x-ray: conclusion Intertrochanteric fracture varus deformity [break in the upper part of the femur near the hip].During an
interview on 9/17/25 at 9:57 a.m. with Resident 2 in her bedroom, Resident 2 confirmed she had pushed Resident 1, Yes, I just pushed her.I got tired of hearing her voice, so I just pushed her and told her to be quiet.During an interview on 9/17/25 at 10:08 a.m. with Licensed Nurse (LN 1), LN 1 stated he was following behind Resident 1 as she walked past Resident 2, Resident 2 stood up and pushed Resident 1 with both hands. Resident 1 fell on the ground landing on her left hip/leg and could not move her left foot.
LN 1 stated when the facility received the x-ray results for Resident 1, she was transferred to the hospital for a left hip fracture.During an interview on 9/17/25 at 12:38 p.m. with the Director of Nursing (DON), the DON confirmed Resident 2 pushed Resident 1 which caused her to fall to the floor and resulted in a left hip fracture. The DON stated all residents have the right to be free from abuse.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Program, dated 4/21,
the P&P indicated, Residents have the right to be free from abuse.This includes but is not limited to.physical abuse.Protect resident from abuse.by anyone including but not necessarily limited to.other residents.
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
Event ID:
GRAMERCY COURT in SACRAMENTO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SACRAMENTO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAMERCY COURT or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.