Inspection Reports for
Carlton Senior Living Sacramento

The complaint was substantiated regarding staff not treating the resident with dignity and respect, but unsubstantiated regarding staff yelling at the resident. The investigation included interviews, video footage review, and collateral interviews. Staff 3 was terminated and the facility conducted mandatory staff training on personal rights and dementia care.

The investigation substantiated that Staff 3 did not treat Resident 1 with dignity and respect by calling the resident 'stupid' in a frustrated tone. However, the allegation that staff yelled at the resident was unsubstantiated due to insufficient evidence. The facility took corrective actions including staff training and termination of Staff 3.

The complaint investigation was substantiated for allegations of inadequate pest control, failure to provide bathing services, and unsanitary resident room conditions. The allegations regarding clean linens and personal rights violations were unsubstantiated.

The investigation substantiated that the facility failed to adequately treat for pests, did not ensure a resident was provided bathing services, and did not maintain a resident's room in clean sanitary conditions. Two other allegations regarding clean linens and personal rights violations were found unsubstantiated.

The complaint alleged that staff were not meeting residents' care needs. The allegation was substantiated based on evidence including care notes, interviews, and records review.

The investigation found that resident R1 was not receiving necessary incontinent care, had multiple falls without an updated strategic fall prevention plan, and care plans were not adequately updated to reflect changes in resident needs. The allegation was substantiated.

The complaint investigation was substantiated. The resident (R1) sustained multiple falls, including a fatal fall on 2024-05-29. The facility failed to provide adequate supervision and did not update care plans or increase monitoring after prior falls. A civil penalty of $500 was assessed due to injury resulting from these violations.

The investigation found that a resident (R1), identified as a fall risk, sustained multiple falls including a fatal fall on 2024-05-29 due to inadequate supervision and failure to implement effective fall prevention strategies. The facility did not update the Individual Service Plan appropriately or increase supervision after prior falls, leading to a substantiated violation and a civil penalty.

The complaint was substantiated. Resident R1 sustained multiple falls, including one that resulted in death due to intraparenchymal hemorrhage from a ground level fall. The facility failed to supervise R1 adequately and did not update care plans to mitigate fall risks. Staff schedules and supervision in the common area were unclear. A civil penalty of $500 was assessed with additional penalties under evaluation.

The investigation found that resident R1, identified as a fall risk, sustained multiple falls resulting in serious injury and death. The facility failed to provide adequate supervision and did not update or implement effective fall risk mitigation strategies. Staff interviews revealed inconsistent resident checks and unclear supervision responsibilities. The allegation was substantiated.

The visit was complaint-related due to a resident's elopement incident on 7/23/2023. The resident was identified as unable to leave unassisted by physician order. The complaint was substantiated as deficiencies were cited and civil penalties assessed.

Resident R1, who was determined unable to leave the facility unassisted, eloped through the rear gate without staff knowledge. Staff mistakenly reset the alarm and delayed egress, allowing the elopement. The resident was found without injury. Deficiencies were cited and a civil penalty of $500 was assessed for immediate violations.