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Complaint Investigation

Gramercy Court

February 25, 2026 · Sacramento, CA · 2200 Gramercy Drive
Citations 1
CMS Rating 4/5
Beds 120
Provider ID 555459
Healthcare Facility
Gramercy Court
Sacramento, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Gramercy Court in Sacramento, CA — inspection on February 25, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies

on 2/25/26 at 10:02 a.m.

Certified Nurses Assistant (CNA) 4, CNA 4 was asked to describe Resident 3

targets them.

She'll start yelling and saying ?Stop trying to kill my daughter,' as an example.During a

room, Resident 3 had a slow, quiet demeanor and smiled when being questioned.She was asked about the incident on 2/4/26 and said, I threw the chair at [Resident 4]. It was heavy.

She was right here.[at another table about 6 feet away]. I think she hurt her hand .

During an interview on 2/25/26 at 11:47 a.m. with the MHW in the conference room, the MHW was asked to describe the incident on 2/4/26 and said, I was standing at the entry to the small dining room on [name of unit] so I could watch the residents inside the dining room and outside in the hall.Then I turned my head, for just a moment, to watch [residents passing through] the hallway and nurses station area.

When I looked back towards the dining room, I saw [Resident 3] stand up, grab her chair and throw it at [Resident 4]. I.couldn't stop it because it all happened too fast.There was also a CNA behind me.[Resident 3] did not say anything. I didn't even notice them talking before this happened.

During an interview on 2/25/26 at 12:30 p.m. with the Nurse Consultant (NC), the NC said, I know [Resident 4] was refusing care, didn't want them to look at it and didn't want medications.

That might have been the reason for the delay in the Xray .

During an interview on 2/25/26 at 12:14 p.m. with the Assistant Director of Nurses (ADON), the ADON was asked what her expectation was regarding abuse toward residents and stated, Our residents should be free from abuse.During a review of the facility policy and procedure (P&P), titled Abuse, Neglect, Exploitation and Misappropriation Prevention, revised 4/21, the P&P indicated, Residents have the right to be free from abuse.This includes.physical abuse.

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.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.