Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gramercy Court during CMS and state inspections, most recent first.
Failure to Protect Residents from Peer Abuse: Multiple residents with serious behavioral health diagnoses and varying cognitive status were involved in peer-to-peer abuse incidents. One resident threw coffee on another resident, one resident pushed a walker into another resident's legs, one resident pressed a lit cigarette butt onto another resident's face, one resident punched another resident in the face, and one resident hit another resident in the back of the head. Witness statements and clinical notes confirmed the incidents, and one resident reported feeling unsafe around the involved peer.
The facility failed to protect a resident from physical abuse when a cognitively intact resident with schizophrenia entered another cognitively intact resident’s room without permission, refused to leave when asked, and, after being pushed out, punched her in the face twice. A nurse witnessed the assault, and the Social Services Director identified the event as physical abuse under the facility’s abuse prevention policy, which guarantees residents freedom from physical abuse.
A resident with schizoaffective disorder and a history of assaultive behavior, care planned as at risk for physical aggression, suddenly stood up in the dining room and threw a heavy metal-framed chair at another resident with schizophrenia who was waiting nearby for a smoke break. A mental health worker observing the area briefly turned away to monitor other residents, and during that moment the chair was thrown, with no reported verbal exchange immediately beforehand. The targeted resident blocked the chair with a hand, later found on radiology to have soft tissue swelling and a mild fracture of the ring finger, and was observed with a hard splint extending from the finger to the elbow. Facility policy stated that residents have the right to be free from physical abuse, and leadership acknowledged that residents should be free from abuse.
The facility failed to protect several residents from physical abuse by other residents, contrary to its abuse-prevention policy. In separate incidents, a resident was slapped on the back of the head, another was punched in the face while in bed, a third was struck in the face resulting in a cut lip, and another was pushed to the floor after a verbal altercation, causing back and leg pain. These events involved residents with schizophrenia and varying levels of cognitive impairment and functional dependence, and were witnessed or confirmed by CNAs and the involved residents. The DON stated that all residents were expected to be free from abuse and safe, but multiple resident-to-resident assaults still occurred.
A resident with schizoaffective disorder and cognitive decline repeatedly abused other residents with serious mental health conditions. In one incident, the resident spat on another resident who was speaking loudly in the hallway. On a separate occasion in the dining room, the same resident stood up from a wheelchair, approached another resident seated at a table, and slapped him on the back of the head, an event witnessed by a social services assistant. In a third incident near the nurse’s station, the resident sat next to another resident attending a group and suddenly slapped her in the face, which was observed by an LPN. The DON later confirmed these witnessed events as physical abuse, in violation of the facility’s abuse prevention policy.
Kitchen sanitation, food storage, and sanitizer testing failures were observed in the dietary department. The CDM confirmed multiple unclean surfaces and equipment, including floors, racks, refrigerator doors, pots and pans, a prep area, a garbage can, and the dishwasher, along with soiled kitchen cloths and a musty mop head stored in the dry storage room. Food items were found improperly covered, unlabeled, expired, dented, moldy, or opened, and staff personal drinks were stored in a resident refrigerator. Staff also could not properly explain or demonstrate sanitizer testing, and expired test strips were being used.
Uncomfortable Room Temperatures: Two residents sharing one room and another resident in a separate room were found in cold rooms below the facility’s stated 71 to 81 degree F range. The residents said they were cold and uncomfortable, and one resident reported staff had recently tried to fix a heater or thermostat issue. The ESS confirmed low temperatures, noted no room-specific temperature monitoring or documentation after attempted adjustments, and the facility policy required comfortable and safe temperatures.
Controlled medications were not handled and documented accurately. Two medication carts contained easily retrievable bags of discontinued controlled drugs stapled to controlled drug records, and staff described holding these medications in the carts until the DON picked them up for destruction. For a resident receiving hydromorphone for pain management, one administration time was missing from the CDR, and the bottle volume did not match the documented remaining amount; the DON confirmed the discrepancy and stated the records were expected to be complete and reconcilable.
A resident with dementia and a history of falls was pushed by another resident with moderate cognitive impairment, resulting in a hip fracture. The incident was witnessed by an LPN and confirmed by the DON, with the aggressor admitting to the action. Facility policy requires protection from abuse by anyone, including other residents.
A resident with significant mental health disorders was physically assaulted by another resident, resulting in injuries such as a bleeding lip and scratches. Both individuals were documented as incapable of understanding their rights. The aggressor was previously observed exhibiting delusional and aggressive behavior, and later admitted to repeatedly hitting the other resident. The incident was confirmed by the DON, and facility policy requires protection from abuse by anyone, including other residents.
A resident with moderate cognitive impairment and a mental health condition was physically abused by another resident during a smoke break, when one resident slapped the other in response to an accidental wheelchair incident. Staff were present and witnessed the event, but failed to prevent the altercation, resulting in the affected resident experiencing pain and feelings of unsafety.
A resident with cognitive impairment physically assaulted another cognitively intact resident after an altercation involving a mental health worker. The incident resulted in the assaulted resident sustaining a head injury and a skin tear, requiring medical evaluation. Facility records and staff interviews confirmed the event, and the DON acknowledged the expectation that all residents be protected from physical abuse.
A resident with bipolar schizoaffective disorder and good cognitive status eloped from the facility after accessing a basketball patio area where exit doors were unlocked, lacked functioning alarms, and had non-working security keypads. Staff confirmed the area was under renovation and should not have been used by residents, but the unsecured exits allowed the resident to leave undetected.
The facility failed to properly store and label medications, with personal belongings found in a medication room, expired and unidentifiable medications in carts, and a resident's ointment left at the bedside without proper authorization. Additionally, a treatment cart was left unlocked, violating facility policies.
A resident with a left hip fracture and moderate memory impairment was observed with her back and side exposed while sitting in a wheelchair, failing to maintain her dignity. Staff confirmed the exposure and acknowledged the need for additional coverage, as per the facility's dignity policy.
A resident was prescribed three psychotherapeutic drugs without obtaining informed consent, as required by the facility's policy. Despite the resident's intact cognition and diagnosis of anxiety, the facility failed to document consent for buspirone, duloxetine, and lorazepam. Interviews with staff confirmed the oversight, highlighting a lapse in following the policy that mandates consent every six months and upon changes in medication or risk.
A resident was found with medications accessible at her bedside without a completed self-medication administration assessment. The resident, admitted with anxiety and having intact memory, had anti-fungal, anti-itching, and antibiotic creams given by staff for bedside use. The ADON confirmed these should have been locked, and the DON noted the absence of a required assessment, which is against facility policy.
A facility failed to complete a discharge MDS assessment for a resident within the required 14-day timeframe after the resident was discharged to the hospital. The oversight was confirmed by the MDS Coordinator and DON, who acknowledged that the assessment should have been completed and submitted promptly according to the RAI manual.
A facility failed to develop a hospice care plan for a resident admitted with multiple diagnoses, including frequent falls, malnutrition, and palliative care needs. During interviews and record reviews, both an LN and the DON confirmed the absence of a hospice care plan, which was against the facility's policy requiring coordination with the hospice plan of care.
The facility failed to adhere to physician orders and professional standards for three residents. A resident's hospice care order was not transcribed to the OSR, another resident's heparin sodium order was incorrectly recorded as an intramuscular injection, and a third resident was given metformin without food, contrary to the physician's order. These deficiencies were confirmed by the DON and licensed nurses, highlighting a lack of adherence to facility policies.
The facility failed to properly monitor and manage psychotropic medications for two residents. One resident did not receive an annual gradual dose reduction for medications used for anxiety, while another was given lorazepam PRN for more than 14 days without a stop date or rationale. These actions were against the facility's policies.
The facility failed to provide weekly and alternate menus to three residents, impacting their ability to choose meals according to their preferences. Residents expressed dissatisfaction with the lack of menu options, and staff interviews revealed a breakdown in the menu distribution process. The Dietary Supervisor prepared menus, but they were not distributed to residents as required by facility policy.
A resident with type 2 diabetes mellitus was not provided with the necessary adaptive eating equipment as ordered by an occupational therapist. The resident's meals were served on a single plate instead of in bowls, as required, leading to difficulty in eating. This was confirmed by both a licensed nurse and the DON, highlighting a failure to adhere to the facility's policy on meal assistance.
During a survey, expired and undated food items were found in the facility's kitchen, including spices, dried beans, lactose-free drinks, bread, cheese, and turkey. The Dietary Supervisor confirmed these items were improperly stored, and the Director of Nursing emphasized the importance of maintaining sanitary conditions to prevent food-borne illnesses.
A resident with chronic pain conditions did not receive timely pain medication upon admission, leading to prolonged periods of severe pain. The facility failed to reassess the resident's pain within the required timeframe after medication administration and inconsistently offered non-drug interventions. Interviews with the DON and nursing staff confirmed these deficiencies, highlighting a lack of adherence to the facility's pain management policy.
The facility did not report the results of an investigation into a resident-to-resident altercation to the State Survey Agency within the required 5 working days. The incident involved two residents, one with schizophrenia and the other with Alzheimer's disease. The Director of Nursing acknowledged the failure to comply with the facility's policy, which mandates reporting alleged abuse violations and investigation results within the specified timeframe.
A resident's right to respect and dignity was compromised when the facility failed to maintain an accurate inventory of personal property, resulting in the loss of the resident's mobile phone. The resident was admitted with the phone, confirmed by staff and the resident's wife, but it was missing upon discharge. The inventory was incomplete, undated, and unsigned, not adhering to facility policy.
A resident required CPR, but two CNAs provided it without current certification, contrary to facility policy. The resident, with a full code status, was found unresponsive, and CPR was initiated by CNAs who did not call 911. The facility's policy mandates CPR by certified staff or calling 911 if the responder is uncertified. Interviews confirmed the CNAs' lack of certification and inadequate training, highlighting a deficiency in CPR policy implementation.
A resident with a history of elopement and under conservatorship eloped during a group outdoor walking activity due to inadequate supervision. Despite being identified as at risk for elopement, the resident was not properly monitored by the four staff members supervising the activity. The staff failed to notice the resident's departure, and the facility's protocols for supervision were not effectively followed.
A resident with schizophrenia was struck by another resident with schizoaffective disorder, resulting in injuries requiring hospitalization. The incident occurred because CNAs present did not attempt verbal de-escalation, contrary to facility policy. The facility's policy mandates staff training in managing aggressive behavior to prevent abuse.
A facility failed to provide safe pharmaceutical services when a nurse left a resident's brimonidine eye drops unsupervised in the room. The resident, with moderately impaired cognition and multiple diagnoses, had their eye drops misplaced and later found on a food tray. Facility policy requires staff to be present during medication administration and to keep medications locked when not in use.
Failure to Protect Residents from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when multiple peer-to-peer incidents occurred involving residents with behavioral health diagnoses and varying levels of cognitive impairment. The report states that Resident 2 had schizophrenia and severe cognitive impairment, Resident 3 had schizoaffective disorder, borderline personality disorder, and anxiety disorder with intact cognition, Resident 4 had schizophrenia, dementia, and depression with severe cognitive impairment, Resident 5 had schizoaffective disorder, anxiety disorder, and depression with intact cognition, Resident 6 had schizoaffective disorder and bipolar disorder with intact cognition, and Resident 7 had schizophrenia, bipolar disorder, depression, and pervasive developmental disorder with severe cognitive impairment. Resident 2 was observed and reported to have thrown a cup of coffee onto Resident 3 after questioning him about staring. Resident 3 stated Resident 2 approached him in the dining hall, asked why he was staring, and then threw coffee from a cup onto his face, neck, and clothing. CNA 2 and an MHW both stated they witnessed Resident 2 throw the coffee toward Resident 3, and Resident 3 then pushed a chair toward Resident 2. The behavioral health note documented the incident as Resident 2 becoming agitated and throwing coffee onto Resident 3. Resident 1 was involved in several separate incidents with other residents. One note stated Resident 1 followed Resident 4 in the hallway and pushed his walker into the back of Resident 4's legs, and CNA 4 stated the contact appeared intentional. Another note and witness statements described Resident 1 approaching Resident 5 in the smoking area and pressing a lit cigarette butt onto Resident 5's face under the right eye, leaving a small scar observed later. Additional notes and witness statements described Resident 1 striking Resident 2 in the face with his fist while they were waiting for a smoke break. Resident 7 was also involved in an incident in which he approached Resident 6 from behind and hit him in the back of the head with his hand while they were in line for snacks, and Resident 6 reported feeling unsafe around the involved peer. The facility policy stated residents have the right to be free from abuse, including physical abuse, and to be protected from abuse by anyone including other residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse when one cognitively intact resident entered another cognitively intact resident’s room without permission and then punched her in the face. The first resident, admitted with schizoaffective disorder and documented as cognitively intact with a BIMS score of 14, reported that the other resident came into her room, stood about two feet inside, and stared at her. She stated that she asked him to leave, but he remained in her room, prompting her to push him out. According to the behavioral health note and staff interviews, after being pushed out of the room, the second resident, who had schizophrenia and a BIMS score of 13 indicating intact cognition, swung his arm twice at the first resident’s face. A licensed nurse, who was near the incident and responded after hearing yelling, confirmed witnessing the second resident punch the first resident in the mouth area twice. The Social Services Director characterized the incident as physical abuse, and the facility’s abuse prevention policy states that residents have the right to be free from physical abuse, including corporal punishment and other forms of abuse.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Finger Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident threw a chair that caused injury. One resident with schizoaffective disorder, a history of assaultive behavior, poor impulse control, fixated delusional thoughts, and agitation was care planned as being at risk of becoming physically aggressive toward others, with interventions to assess and anticipate needs and intervene before agitation escalates. Another resident with schizophrenia and a history of assaultive behavior was care planned as being at risk for behavioral disturbances, with an intervention to provide a secure and comfortable environment. Both residents were documented as alert, oriented, and able to make their needs known. On the day of the incident, the two residents were in the small dining room waiting for a smoke break. According to nursing notes and staff interviews, the resident with schizoaffective disorder suddenly stood up, lifted the chair she had been sitting on, and threw it toward the other resident, stating she believed the other resident was going to hurt her brother. A mental health worker, positioned at the entry to the dining room to observe residents inside the room and in the hallway, briefly turned away to watch residents passing through the hallway and nurses’ station area. When the worker looked back, the resident had already stood up, grabbed the chair, and thrown it; the worker reported the event happened too quickly to intervene and did not recall any verbal interaction between the two residents immediately beforehand. The resident who was struck reported that she blocked the incoming chair with her hand, describing the chair as heavy with a metal frame and padded seat, back, and armrests. She stated that her ring finger was broken, that it did not hurt at the time of the interview, and that she believed the act was intentional, possibly related to something said previously. Radiology results documented soft tissue swelling and a mild fracture. At the time of surveyor observation, the injured resident had a hard splint from the ring finger to the left elbow wrapped with gauze. Facility policy on abuse, neglect, exploitation, and misappropriation prevention stated that residents have the right to be free from abuse, including physical abuse, and the ADON affirmed that residents should be free from abuse.
Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite a policy stating residents have the right to be free from abuse and neglect and must be protected from abuse by anyone, including other residents. One resident with schizophrenia, major depression, anxiety disorder, and moderate cognitive impairment (BIMS 10/15) was slapped on the back of the head by another resident with schizophrenia, memory loss, and severe cognitive impairment (BIMS 3/15), as witnessed by a CNA; the victim later reported feeling upset. In another incident, a resident with schizophrenia and intact cognition (BIMS 13/15) was documented as striking his roommate, a resident with schizophrenia, need for assistance with personal care, and moderately impaired cognition (BIMS 12/15), while appearing highly psychotic, unable to follow directions, and aggressive toward staff. The roommate later stated he was punched in the face while in bed and felt scared, and a CNA reported seeing punches thrown. Additional incidents included a resident with schizophrenia and need for assistance with personal care, with intact cognition (BIMS 13/15), entering the room of the same moderately cognitively impaired resident, who then struck him in the face, causing a mild tear and slight bleeding of the lip; the aggressor later confirmed hitting the other resident on the lip. In a separate event, a resident with schizophrenia, restlessness, agitation, and severe cognitive impairment (BIMS 6/15) engaged in a verbal altercation with another resident with schizophrenia, difficulty walking, memory problems, chronic pain syndrome, and moderate cognitive impairment (BIMS 10/15), which escalated to the first resident pushing the second. The pushed resident reported being shoved on the shoulders, falling to the ground, and experiencing back and leg pain, and a CNA confirmed witnessing the intentional push that caused the fall. The DON stated her expectation that all residents be free from abuse and safe in the facility, but the documented resident-to-resident assaults demonstrate that residents were not protected from physical abuse as required by facility policy.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident on three separate occasions. Resident 1, who had schizoaffective disorder and age-related cognitive decline, was admitted in December 2025. On 12/13/25 at approximately 4 p.m., Resident 1 was standing in the hallway using a walker when Resident 2, who had schizoaffective disorder and depression, was positioned in front of him and speaking loudly to himself. Resident 1 became upset by Resident 2’s behavior and spat on Resident 2. Resident 2 later confirmed that another resident had spit on him about a month prior and expressed more concern about staff than other residents when asked if he felt safe. On 12/24/25, Resident 1 physically abused Resident 3 in the dining room. Resident 3, who had schizophrenia and dementia and had been admitted in April 2024, was seated at a table drinking coffee. Resident 1 was observed standing from his wheelchair, approaching the table where Resident 3 was seated, and then slapping Resident 3 on the back of the head, producing an audible sound. A social services assistant witnessed the incident and reported that Resident 3 looked shocked and confused, and that Resident 1 stated he slapped Resident 3 because Resident 3 was looking at him in a “weird way.” Resident 3 later stated he had been hit on the back of the head by “some guy,” though he did not recall exactly when. On 12/26/25, Resident 1 physically abused Resident 4 near the nurse’s station. Resident 4, who had schizoaffective disorder and PTSD and had been re-admitted in March 2024, was sitting near the nurse’s station attending a group when Resident 1 walked toward her, sat down next to her, and suddenly struck the right side of her face with his hand. A licensed nurse witnessed the event, described hearing an audible slap, and reported that Resident 4 cried and said that Resident 1 had slapped her. During a later interview, Resident 4, who demonstrated confusion and difficulty providing appropriate responses, expressed fear about a fire and recounted being slapped by a man, stating it was her word against everybody else. The DON confirmed that the three witnessed incidents between Resident 1 and Residents 2, 3, and 4 constituted physical abuse, contrary to the facility’s abuse prevention policy, which states residents have the right to be free from physical abuse and other forms of mistreatment.
Kitchen sanitation, food storage, and sanitizer testing failures
Penalty
Summary
Food storage and preparation areas were found unclean and unsanitary during observations in the kitchen with the Certified Dietary Manager (CDM). The kitchen floors had food stains and debris in the corners, the grill stove panel, rolling cart racks, and refrigerator doors were smeared with white and black substances, and a blue garbage can near the food preparation area had food debris and streaks on the outside. Pots and pans on a fixed rack had food crumbs and stains, the stainless-steel area used for coffee, tea, and water pitchers had dried white streaks and brown stains, the shelf below had a large dried dark brown stain, and the dishwasher had thick residue along the panel near the motor mechanism. A rolling container labeled for kitchen rags held towels and a grease-stained mop head that smelled musty in the dry food storage room, and the CDM stated there was no weekly cleaning log sheet identifying staff duties. Food items and staff personal items were also found improperly stored. Potato salad was found loosely covered with no open date label and an expired date written on the container in the walk-in refrigerator. Three staff personal drinks were found in the residents' refrigerator, and a dented zero sugar cola can was on the bottom shelf of that refrigerator. In the dry food storage room, an opened caramel sauce bottle had a white sticky substance leaking from the top, and an unidentified moldy food item wrapped in plastic and foil was found on an opened box of tartar sauce next to staff lockers. The CDM stated the unidentified food item belonged to kitchen staff and acknowledged expectations for discarding expired items, labeling opened foods, and keeping personal food and drink in appropriate staff areas. Kitchen staff were unable to explain or demonstrate proper testing of sanitizer solutions, and expired test strips were being used. A dietary aide attempted to test dishwasher sanitizer using chlorine test paper but did not obtain the expected result, and another dietary aide and the CDM then used a different company's test strip for QUAT solution. Both chlorine test paper bottles had an expiration date of 09/25, and the CDM stated staff had not had return demonstration education on testing dishwasher chlorine sanitizing solution or QUAT solution. The [NAME] also stated there was no QUAT solution test form to document results, and the CDM confirmed no such form existed. The Administrator stated the expectation was for kitchen staff to maintain cleanliness and follow protocols for food preparation and temperatures.
Uncomfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for three sampled residents when the shared room of two residents and the room of one resident were below 71 degrees F. Resident 62, who had epilepsy and a BIMS score of 9, and Resident 120, who had metabolic encephalopathy and a BIMS score of 13, shared a room that was observed at 69 degrees F during one visit and 67 degrees F during another. Both residents stated the room felt cold and uncomfortable, and Resident 120 reported that staff had recently tried to fix a heater or thermostat issue. During the observation of the shared room, the Environmental Services Specialist and Maintenance Assistant measured room surfaces and confirmed the low temperature. The ESS stated that temperature issues were reported through the communication logbook and were addressed in a timely manner, but also confirmed there was no room-specific temperature monitoring or documentation after attempted adjustments on the dates the room was reported too cold and too hot. The ESS stated the facility should maintain temperatures between 71 and 81 degrees F. Resident 61, who had schizoaffective disorder and a BIMS score of 10, was also observed experiencing a cold room environment. He was seen wearing multiple layers and blankets and stated that his room and the facility were very cold. His room temperature was later measured at 64.5 degrees F, and the ESS again stated that resident room temperatures should be maintained between 71 and 81 degrees F for resident comfort. The facility policy on Homelike Environment also stated that residents are to be provided a safe, clean, comfortable, and homelike environment with comfortable and safe temperatures between 71 degrees F and 81 degrees F.
Controlled Medication Storage and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate handling, storage, disposal, and documentation of controlled medications for residents in a census of 101. During observation and interview, two medication carts contained bags of discontinued controlled substances that were still easily retrievable inside cart drawers. Licensed nurses confirmed the bags held multiple uncrushed controlled drugs in small plastic bags stapled to folded controlled drug records, and one nurse stated the medications had been held in the cart for over a week. The DON stated discontinued controlled substances were expected to be destroyed within no more than three days, and that storing them for a month was not acceptable. The facility’s staff described a process in which discontinued controlled medications were placed in small plastic bags, stapled to controlled drug records, folded, and then placed in larger bags until the DON picked them up for destruction with the pharmacist. However, staff also confirmed there was no controlled drug destruction at the medication carts and no controlled drugs were placed in unretrievable medication bins. The facility policy stated that when a resident receives a partial tablet or it is not given, the medication is destroyed, and that disposal methods are used to prevent diversion and accidental exposure. For Resident 98, who was readmitted in fall 2025 with diagnoses including malignant kidney neoplasm, palliative care, and rheumatoid arthritis, the order was for hydromorphone 3 mL by mouth every 3 hours for pain management. The shipping manifest showed 60 mL of hydromorphone 5 mg/mL was received, and the MAR showed 19 mL remained after administration. On review of the controlled drug record, one administration time was missing for a 2 mL dose on 12/2/25, and the record indicated 19 mL remained to be wasted. When the DON reviewed the bottle, it contained 30 mL instead of 19 mL, and she acknowledged the discrepancy and stated the controlled drug records were expected to be completed and reconcilable.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 1, who had diagnoses including anxiety disorder, dementia, a history of falls, and a mental health condition with hallucinations and mood swings, was observed walking in the hallway. Resident 2, who had anxiety disorder, intellectual disabilities, and a similar mental health condition, was seated nearby and suddenly stood up and pushed Resident 1 without warning. This action caused Resident 1 to fall onto her left side, resulting in limited mobility in her left leg and hip. An x-ray confirmed an intertrochanteric fracture with varus deformity near the hip, and Resident 1 was subsequently transferred to the hospital for further care. Interviews confirmed that Resident 2 admitted to pushing Resident 1 because she was tired of hearing her voice. A licensed nurse witnessed the incident, stating that Resident 2 stood up and pushed Resident 1 with both hands, causing the fall and injury. The Director of Nursing confirmed the incident and acknowledged that all residents have the right to be free from abuse. Review of the facility's policy indicated that residents must be protected from abuse by anyone, including other residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had a history of mental health disorders including hallucinations, delusions, anxiety, impulse disorder, and mood disorder, was found with injuries including a bleeding lip, scratches on the forearm, and redness to the hand knuckles after being punched in the face by another resident. Both residents involved were documented as incapable of understanding their rights, responsibilities, and informed consent. Prior to the physical altercation, the aggressor was observed yelling profanities and exhibiting racially preoccupied, delusional behavior toward the victim. Progress notes and interviews confirmed that the aggressor admitted to repeatedly hitting the other resident until he fell to the floor. The incident was acknowledged by the DON, who confirmed that all residents have the right to be free from abuse. The facility's policy also states that residents must be protected from abuse by anyone, including other residents. The failure to prevent this altercation resulted in physical harm to the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a mental health condition was physically abused by another resident. The incident took place during a smoke break, when the first resident, while maneuvering his wheelchair, accidentally rolled over the other resident's foot. In response, the second resident slapped the first resident on the left cheek, causing immediate pain rated as 8 out of 10. The event was witnessed by a mental health worker, who reported hearing a loud slapping sound and observed the affected resident holding his face in pain. The incident was also confirmed by the Director of Nursing, who acknowledged that staff were present at the time but failed to prevent the altercation. The affected resident reported feeling unsafe and disrespected as a result of the incident. Facility records and interviews confirmed that the altercation was witnessed by staff, and that the facility's policies require protection of residents from abuse, including abuse by other residents. Despite these policies and staff presence, the facility failed to prevent the physical abuse, resulting in both physical and emotional harm to the resident.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and bipolar type, who was cognitively intact, was physically assaulted by another resident with schizophrenia and severely impaired cognition. The incident took place when the cognitively intact resident attempted to intervene during an altercation between the second resident and a mental health worker. The second resident, after being told to wait his turn during an exercise group, became agitated, held the mental health worker down, and spat on her. The first resident intervened to assist the staff member, at which point the second resident pushed the first resident against a wall, causing the resident's head to hit the wall and resulting in a skin tear on the right elbow, a bump to the head, and subsequent complaints of headache, nausea, and dizziness. Facility records and staff interviews confirmed that the altercation was witnessed and documented, and that the resident who was assaulted required transfer to a medical center for further evaluation. The facility's policy states that all residents have the right to be free from abuse, including abuse by other residents. The Director of Nursing acknowledged that residents should be protected from physical abuse within the facility. The failure to prevent this incident resulted in the resident not being free from abuse as required by facility policy.
Resident Elopement Due to Unsecured Exit During Patio Renovation
Penalty
Summary
The facility failed to maintain a safe environment for one resident who eloped from the premises through an unsecured exit gate. The resident, admitted with a diagnosis of bipolar schizoaffective disorder and assessed as having good memory and judgment, was outside on the basketball court patio with other residents when staff noticed the resident was missing. A search was conducted, but the resident was not found on the premises. Observations revealed that the basketball patio area had two exit doors with non-functioning security keypads, no working alarm speaker boxes, and both doors were unlocked and easily opened, leading directly to the parking lot. Staff confirmed that the area was under renovation and should not have been accessible to residents, and that the exit gates were not secured or alarmed as required. Facility policies reviewed indicated that all doors and locking mechanisms should always be working to prevent such incidents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which was observed during a survey. Personal belongings were found in the Hall C medication room, which were confirmed to belong to a licensed nurse. Expired medications were discovered in two medication carts, with one cart containing 31 expired pills of carvedilol and another cart containing unidentifiable medications with unreadable labels. Additionally, two multi-dose liquid protein bottles without open dates and an expired inhaler were found in a medication cart. The liquid protein bottles were opened and partially used without being marked with open dates as required by the manufacturer's instructions. Furthermore, a tube of menthol ointment was found on a resident's bedside table without a physician's order for self-administration or bedside storage. The Director of Nursing confirmed that personal belongings should not be stored in medication rooms, and expired or discontinued medications should be removed from carts. Additionally, a treatment cart was left unlocked and unattended for 10 minutes while a treatment nurse was providing wound care, which could allow unauthorized access to medications. The facility's policies require medications to be stored in locked compartments and for medications brought by residents to be kept in the med cart unless approved for bedside storage by a physician.
Failure to Maintain Resident Dignity Due to Inadequate Clothing Coverage
Penalty
Summary
The facility failed to promote dignity for a resident, identified as Resident 27, who was observed wearing a gown with her back and side of her body exposed while sitting in a wheelchair. This incident was noted during an observation where Resident 27 wheeled herself into the hallway, and staff did not cover her exposed back. The resident had been admitted to the facility with a diagnosis of a left hip fracture and required substantial to maximal assistance with dressing due to moderate memory impairment. Further observations revealed that Resident 27's back and side were exposed while she was sitting in her wheelchair near the entrance of her room, with staff and other residents passing by. Certified Nursing Assistants (CNAs) confirmed the exposure and acknowledged that it should have been covered with another gown or shirt. The Director of Nursing also stated that Resident 27 would feel embarrassed by the exposure and expected staff to provide a second gown for coverage. The facility's policy on dignity emphasized caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Obtain Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotherapeutic drugs for a resident, identified as Resident 43, who was prescribed three such medications without proper consent. Resident 43 was admitted to the facility with a diagnosis of anxiety and had intact cognition as per the Minimum Data Set assessment. The resident was prescribed buspirone, duloxetine, and lorazepam, but there was no documentation of informed consent for these medications in the resident's medical record. During interviews with the Medical Record staff, Assistant Director of Nursing, and Director of Nursing, it was confirmed that informed consent was not obtained for the psychotherapeutic drugs prescribed to Resident 43. The facility's policy requires informed consent to be obtained every six months for such medications, and further consent is needed if there are changes in medication or risk. However, the facility did not adhere to this policy, as evidenced by the lack of informed consent documentation for the prescribed medications.
Failure to Complete Self-Medication Assessment for Resident
Penalty
Summary
The facility failed to complete a self-medication administration assessment for a resident, identified as Resident 43, who had medications accessible and stored on top of a bedside table. Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety and had a perfect score on a mental status assessment, indicating intact memory. During an observation and interview, it was noted that Resident 43 had a plastic container with multiple anti-fungal, anti-itching, and antibiotic creams at her bedside, which she stated were given to her by the nurse and certified nursing assistant for her to keep at bedside when needed. The Assistant Director of Nursing confirmed the presence of these medications at the resident's bedside and acknowledged that they should have been kept locked in the medication cart. Further review of Resident 43's medical record revealed no Self-Medication Administration Assessment had been completed. The Director of Nursing also confirmed the absence of this assessment and stated that medications should not be left at the bedside as other residents could potentially access them. The facility's policy on self-administration of medications requires an interdisciplinary team to determine if it is clinically appropriate and safe for a resident to self-administer medications.
Failure to Complete Discharge MDS Assessment on Time
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident within the required timeframe. The resident was admitted to the facility and discharged to the hospital 13 days later. However, the discharge assessment was not completed and submitted within 14 calendar days as mandated by the Resident Assessment Instrument (RAI) manual. This oversight was confirmed during interviews and record reviews with the Business Office Consultant, MDS Coordinator, and Director of Nursing. The MDS Coordinator acknowledged that the discharge assessment should have been completed and submitted within the specified timeframe. The Director of Nursing also confirmed that the assessment should have been completed immediately after the resident's transfer to the hospital. The facility's policy on MDS completion and submission timeframes, which aligns with the RAI manual, was not adhered to in this instance, leading to the deficiency.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a hospice care plan for Resident 254, who was admitted in November 2024 with multiple diagnoses, including frequent falls, malnutrition, and palliative care needs. During interviews and record reviews conducted on December 5, 2024, both a Licensed Nurse (LN 1) and the Director of Nursing (DON) confirmed that no hospice care plan had been developed for Resident 254. This oversight was contrary to the facility's policy, which requires obtaining the most recent hospice plan of care specific to each resident and coordinating it with the care and services provided by the facility.
Failure to Adhere to Physician Orders and Professional Standards
Penalty
Summary
The facility failed to provide services according to professional standards of quality for three residents. Resident 254's physician order to admit to hospice care was not transcribed to the order summary record (OSR), despite being noted in the progress notes. This oversight was confirmed by both a licensed nurse and the Director of Nursing (DON) during a review of the resident's records. The facility's policy on hospice care requires coordination with the care and services provided, which was not adhered to in this instance. Resident 255's physician's order for heparin sodium was incorrectly recorded in the OSR as an intramuscular injection instead of subcutaneous, which could cause muscular tissue damage. This error was identified and confirmed by both a licensed nurse and the DON. Additionally, Resident 257 was not given metformin hydrochloride as prescribed by the physician, which required administration with meals. The licensed nurse administered the medication without food, contrary to the physician's order, which was confirmed by the DON. The facility's policy on administering medications requires adherence to prescriber orders, which was not followed in this case.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and management of psychotropic medications for two residents. Resident 43, who was admitted with a diagnosis of anxiety, did not receive an annual gradual dose reduction (GDR) for psychotropic medications, including buspirone, duloxetine, and lorazepam, despite being on these medications for over a year. The Assistant Director of Nursing confirmed that no GDR was attempted in 2023, which was against the facility's policy requiring annual GDR attempts after the first year of medication use. Resident 30, diagnosed with dementia and agitation, was administered lorazepam on a PRN basis for more than 14 days without a stop date or a documented rationale for continued use. The Director of Nursing and Assistant Director of Nursing confirmed that the doctor's order lacked a rationale for extending the PRN order beyond 14 days, which violated the facility's policy limiting PRN psychotropic medication orders to 14 days unless a specific condition necessitated its use.
Failure to Provide Menus to Residents
Penalty
Summary
The facility failed to provide weekly and alternate menus to three residents, which decreased the potential to meet their nutritional and cultural preferences. Resident 204, admitted with a disorder of electrolyte and fluid imbalance, expressed dissatisfaction with the lack of menu options and the inability to choose her food preferences. Similarly, Resident 24, with type 2 diabetes mellitus, reported that he did not like the meals served and was unaware of upcoming meals due to the absence of a menu. Resident 38, diagnosed with morbid obesity and type 2 diabetes mellitus, also expressed uncertainty about meal options and resorted to eating instant noodles when dissatisfied with the facility's food. Interviews with facility staff revealed a breakdown in the distribution process of menus. The Dietary Supervisor stated that menus were prepared weekly with the dietician and left at nurse stations for distribution. However, Licensed Nurse 9 confirmed that nurses were not responsible for distributing menus to residents. The Director of Nursing indicated that the activities department should have distributed the menus, and the dietician should have ensured residents received them. The facility's policy required the activities department to distribute menus and the dietician to confirm their distribution, but this was not followed, leading to the deficiency.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident, identified as Resident 46, who required special eating equipment as per their care plan. Resident 46, who was admitted in July 2020 with a diagnosis of type 2 diabetes mellitus, had an order from an occupational therapist to have meals served in bowls to assist with eating. However, during an observation, it was noted that the resident's lunch was served on a single plate, contrary to the order. The resident was observed transferring food to a cup, indicating difficulty with the provided setup. Licensed Nurse 8 confirmed that the resident's meal was not served according to the order, which was also verified by the Director of Nursing. The facility's policy on meal assistance, revised in March 2022, states that adaptive devices should be provided for residents who need them, and assistance should be given to ensure residents can use and benefit from special eating equipment. This oversight decreased the facility's potential to meet the resident's nutritional needs.
Improper Food Storage and Expired Products Found in Facility
Penalty
Summary
The facility failed to properly store food in accordance with professional standards for food safety, as observed during a survey. During an initial kitchen tour, the Dietary Supervisor (DS) identified several expired food items, including two spice bottles, a box of dried beans, and a 12-pack box of lactose-free drinks, all past their use-by dates. Additionally, undated food products, such as loaves of bread, a block of cheese, and a container of cooked sliced turkey, were found in the dry storage area and walk-in refrigerator. The DS confirmed these items were either expired or lacked proper dating, which is necessary to ensure food safety. The Director of Nursing (DON) stated that kitchen staff are expected to regularly check and clean storage areas, including refrigerators, to maintain sanitary conditions. The facility's policy on Food Receiving and Storage, revised recently, requires that foods be received and stored in compliance with safe food handling practices. The failure to adhere to these standards increased the potential for food-borne illnesses among the residents, as expired and improperly stored food can pose health risks.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 1, who was admitted with multiple diagnoses including cellulitis, chronic pain syndrome, osteoarthritis, and osteonecrosis. Upon admission, the resident was not administered prescribed pain medication for eight hours, despite experiencing severe pain. The facility's records indicated that the resident's pain was not assessed in a timely manner, and non-pharmacological interventions were not consistently offered as per the care plan. The facility's documentation revealed multiple instances where the resident's pain was not reassessed within the expected timeframe after administering pain medication. For example, on several occasions, the reassessment of pain occurred two to three hours after medication administration, contrary to the facility's policy which required reassessment within one hour. Additionally, there were inconsistencies in offering non-drug interventions, and the resident was not always medicated according to the physician's orders, as evidenced by an instance where only one tablet of oxycodone was administered instead of two for severe pain. Interviews with the Director of Nursing (DON) and licensed nurses confirmed these deficiencies. The DON acknowledged the failure to administer pain medication timely and the lack of consistent reassessment of pain. The nursing staff also confirmed that pain reassessment should occur within 30 to 45 minutes post-medication, and if pain relief was ineffective, further interventions should be pursued. The facility's 'Pain Assessment and Management' policy emphasized the importance of timely pain assessment and intervention, which was not adhered to in this case.
Failure to Report Resident Altercation Investigation
Penalty
Summary
The facility failed to complete and report the results of an investigation of a resident-to-resident altercation to the State Survey Agency within the required 5 working days. This incident involved two residents, one with schizophrenia and major depressive disorder, and the other with Alzheimer's disease and moderate cognitive impairment. The altercation occurred on November 7, 2024, but the results of the investigation were not reported as mandated by the facility's policy. During an interview, the Director of Nursing confirmed the failure to report the investigation results within the stipulated timeframe. The facility's policy, revised in October 2022, clearly states that all alleged violations of abuse and the results of investigations must be reported to the State Agency within 5 working days. This oversight had the potential to subject residents to further incidents of abuse.
Failure to Maintain Accurate Inventory of Resident's Personal Property
Penalty
Summary
The facility failed to ensure respect and dignity for a resident by not maintaining an accurate inventory of the resident's personal property. The resident was admitted with a mobile phone, which was confirmed by the resident's wife, a licensed nurse, and a certified nursing assistant. However, upon discharge, the resident's mobile phone was missing, and there was no signed or provided inventory of personal items at admission or discharge. The inventory of personal effects only listed a watch and a polo shirt, lacked signatures, and was undated, indicating non-compliance with the facility's policy and procedure. Interviews with the Social Services Director, Director of Staff Development, and Director of Nursing revealed that the inventory process was not properly conducted. The facility's policy required a detailed inventory of personal effects to be completed and signed by staff and family members, with a copy provided to the resident or family. The Director of Nursing confirmed that the inventory did not follow the facility's policy, and the resident's mobile phone should have been included. This oversight resulted in the unrecovered loss of the resident's mobile phone.
Deficiency in CPR Policy Implementation
Penalty
Summary
The facility failed to implement its cardiopulmonary resuscitation (CPR) policy for a resident who required emergency resuscitation. Two certified nursing assistants (CNAs) provided CPR to the resident without maintaining current CPR certification. The resident, who had a history of schizoaffective disorder, drug abuse, and diabetes, was found unresponsive with seizure-like activity. Despite the resident's full code status, the CNAs initiated CPR without current certification, and one of them did not call 911. The facility's policy requires that CPR be initiated by a licensed staff member certified in CPR/BLS, or if the first responder is not certified, they should call 911 and follow instructions until certified staff arrive. Interviews revealed that CNA 1 and CNA 2 both assisted in providing CPR without current certification, and neither called 911. CNA 1's CPR card was expired, and CNA 2's CPR certification was not provided. The Director of Staff Development confirmed that during the latest CPR training, only nurses were checked for hands-on CPR skills, not CNAs. The facility's administrator acknowledged that staff providing CPR should have current certification. This deficiency decreased the facility's potential to provide high-quality CPR during emergencies.
Resident Elopement During Outdoor Activity Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident who eloped during a group outdoor walking activity. The resident, who was under conservatorship and had a history of elopement attempts, was admitted with diagnoses including bipolar type schizoaffective disorder and diabetes. Despite being able to walk independently, the resident was identified as at risk for elopement in their care plan. During the walking activity, the resident was part of a group of 19 residents supervised by four staff members. However, the staff did not notice when the resident left the group, and the resident was discovered missing upon the group's return. Interviews with the walking activity staff revealed that although the resident's participation was noted on the sign-in sheet, the staff did not see the resident leave the group. The staff confirmed that they did not conduct a head count during the activity, which contributed to the oversight. The facility's policy and procedure documents emphasized the importance of maintaining a safe environment and supervising residents during group activities, but these protocols were not effectively implemented, leading to the resident's unsupervised departure.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when he was struck in the face by another resident, resulting in a swollen eye, severe headache, and vomiting that required hospitalization. Resident 1, who was admitted with schizophrenia, was attacked by Resident 2, who was admitted with schizoaffective disorder. The incident was documented in the progress notes by a Licensed Nurse, and Resident 2 admitted to striking Resident 1. Interviews with the Program Director and Director of Nursing revealed that the Certified Nursing Assistants present during the altercation did not attempt to verbally de-escalate the situation, which was against the facility's policy. The facility's policy on abuse prohibition and prevention, dated November 2017, requires staff to be trained in appropriate interventions to manage aggressive behavior and prevent abuse. The failure to intervene and de-escalate the situation led to the abuse incident.
Unsafe Pharmaceutical Practices
Penalty
Summary
The facility failed to provide safe pharmaceutical services for a resident when a Licensed Nurse left the resident's brimonidine eye drops unsupervised in the room. The resident, who had moderately impaired cognition and required assistance with personal care, was admitted with multiple diagnoses including primary open-angle glaucoma and insomnia. During a morning medication pass, the Licensed Nurse left the eye drops in the resident's room and stepped out. Upon returning, the nurse found the eye drops missing, which were later discovered on the resident's food tray by kitchen staff. The Certified Nursing Assistant confirmed that the resident was confused and needed redirection, often grabbing and moving items around. The Nursing Supervisor and Director of Nursing both confirmed that the facility's policy required staff to be present when administering medications and that medications should not be left in residents' rooms. The Director of Nursing emphasized that medications should be returned to the medication cart after administration. A review of the facility's policy on medication storage indicated that medication supplies should remain locked when not in use or attended by authorized personnel. The incident was documented in the resident's Progress Note, which indicated that only one eye drop bottle was found at the time, and the other medications were locked in the nurse's cart.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 666 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arden Park Post Acute | 1.2 mi | ★★★★★ | 15 | 0 |
| Woodside Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Asbury Park Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 20 | 0 |
| Sherwood Healthcare Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Mission Carmichael Healthcare Center | 2.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.