Carlton Senior Living Sacramento Atrium

COMPLAINT INVESTIGATION REPORT

This report details a complaint investigation conducted on 09/19/2025 regarding allegations of staff not following service plans, not meeting resident needs, and falsifying records. The investigation found no preponderance of evidence to prove the alleged violations, resulting in the allegation being unsubstantiated. No citations were issued.

The inspection was an unannounced Required 1 Year Annual Inspection. The primary deficiency found relates to medication administration, specifically the failure to provide medication for heart failure for multiple consecutive days. Additionally, the inspector noted deficiencies in the physical plant, including unlabeled food in the refrigerator, freezer, and pantry, and noted equipment issues like a flickering hall light and broken elevator.

The inspection was an unannounced Required 1 Year Annual Inspection. The primary deficiency found relates to medication administration, specifically the failure to provide medication for heart failure for multiple consecutive days. Additionally, the inspector noted deficiencies in the physical plant, including unlabeled food in the refrigerator, freezer, and pantry, and noted equipment issues like a flickering hall light and broken elevator.

The investigation substantiated allegations regarding the improper handling and storage of medications. Specifically, deficiencies were cited for failure to properly destroy and document unused medications, and for leaving multiple resident medications unsecured in the Medication Manager's unlocked desk. These findings indicate immediate risks to resident health and safety.

This report details the investigation of three allegations: medication mismanagement, failure to obtain a hospice care plan, and failure to maintain a comfortable temperature. The investigator found no preponderance of evidence to support any of the allegations.

The facility underwent a required 1-Year Post Licensing visit on 9/17/24. The inspector noted that the administrator certificate and license fees are current, and the physical plant was inspected for safety hazards. No deficiencies were cited during this visit.

The facility underwent a required 1-Year Post Licensing visit on 9/17/24. The inspector noted that the administrator certificate and license fees are current, and the physical plant was inspected for safety hazards. No deficiencies were cited during this visit.