Carlton Senior Living Sacramento Atrium.

S2 stated that R1's room was cleaned right away by staff once the family addressed the concern and an internal investigation was conducted. The investigation found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. On 3/4/26, LPA observed R1 pressed their call button and a care partner arrived to their room within one minute. S2 stated that the ideal response time is 5 minutes but it is “ideally” expected to be no more than 3-10 minutes. Additionally, it was reported that on 3/4/26 at around 3:00 AM, R1 had back pain and they pressed their call button to request a Tylenol (PRN) medication for pain. Staff responded to the call and repositioned them in bed but did not return to give R1 the requested pain medication. S2 stated the missed medication was due to a staff feeling unwell and they went off shift without passing along the information to ensure R1 received the requested PRN medication. Record review and Staff interviews confirm R1 was paying extra for medication management as the services are provided are a la cart. It was reported the facility is not requesting medication in time which may results in R1 missing medication doses on several occasions including 3/5/26 . On 3/9/26, the facility informing contacted R1's family to inform that R1 ran out of cholesterol/blood pressure medications. Record review of R1’s care plan indicated they receive Medication management is “Level 3 (11-20 medications)” and they receive medication management services. Medication and Reporting Requirement guidance was provided to S1 and S2. S2 stated medication was missed due to prescription being expired and they missed due to pharmacy delays March 2026. It was reported that R1 was paying for the extra service to “be walked” and taken to activities but the service was removed since staff not taking R1 on walks or to activities timely or at all. Staff stated "escort services" were provided and there was not a known discrepancy with this service. Additionally, S2 reported on December 8th 2025, there was a complaint reported to the facility by R1's family member (RP), in which R1 reported that care partners were not answering their calls. S2 and S6 corroborate that all of R1's calls were not being answered timely. On December 5th 2025, RP stated she called the community at approximately 1:45pm to request that the resident was dressed and ready for an outing by 4pm. S2 stated the family reported R1's brief was soiled upon arrival and they were not ready by the time requested . Dress Assist services were not met. S6 stated long wait times did occur of up to an hour or no response at all due to previous management and short staffing. Based on interviews and record review, “Staff do not respond to resident's requests for assistance in a timely manner”, is substantiated. CONTINUED ON 9099-C3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation 2: Staff do not ensure that resident's hygiene needs are met. It was alleged “Staff do not ensure that resident's hygiene needs are met”, this investigation focused on Resident 1. Throughout the process, the LPA conducted facility observations, interviewed staff and residents, collateral interviews, and reviewed all relevant documents related to R1. S2 and S5 reported R1 was moved out of the facility as of 3/22/26 due to overall dissatisfaction. Staff corroborated reports that incontinent and hygiene needs were not met for R1. On 3/4/26, S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was dirty and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), did not meet expectations of cleaning R1 and cleaning R1's room. S2 stated S4 reported they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4. S2 stated S3 was terminated. S2 stated, that on 2/26/26, he apartment was not ”up to standard” as it was not cleaned; the room trash bin was not emptied out, and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean it every morning. Staff, R1, and collateral persons interviewed stated showers and bathing are done once per week as stated on their service plan. On 3/4/26, LPA observed R1 and R1’s room was clean and free of odors. LPA was unable to confirm if R1’s wheelchair seat smelled of urine. S6 stated long wait times did occur of up to an hour or no response at all due to previous management (S3) and short staffing. Based on interviews and record review of the allegation “Staff do not ensure that resident's hygiene needs are met”, is substantiated. [CONTINUED ON 9099-C4] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation 3: Staff do not ensure incontinent needs are met. It was alleged “Staff do not ensure incontinent needs are met”, this investigation focused on Resident 1 (R1). Throughout the process, the LPA conducted facility observations, interviewed staff, residents, collateral interviews, and reviewed relevant documents related to R1. S2 and S5 reported R1 was moved out by their family as of 3/22/26 due to overall dissatisfaction. Record review shows R1’s primary diagnosis is Dementia. R1’s “Assisted living assessment” was completed on 06/12/2025 for R1. R1’s Service Plan lists “Continence Care” in which “Resident will be offered assistance with toileting … Continence Care - 60 min/day … Staff will offer approximately 60 minutes of assistance per day while the resident uses the bathroom”. It is indicated that this is the responsibility of the Care Partner. Also, the plan details that the Care Partner “staff to be aware of resident's unique toileting needs. Indicate in notes … Purewick use during overnight”. Medication management is “Level 3 (11-20 medications)”. The “Residence and Service Agreement” state the following: “The appraisals described above and, in this Agreement, including those conducted at the time of admission and thereafter during your residency at The Community, are considered by us in determining, setting and monitoring staffing levels at The Community. We consider the appraisal and other factors to determine, set, or monitor staffing levels at The Community”. The plan recommended the following additional services for R1: Continence Care -Monthly $ 995.00 / Monthly, Dress Assist 2 -Monthly $ 1000.00 / Monthly, Emergency Pendant -Monthly $ 55.00 / Monthly, Escort Assist -Monthly $ 700.00 / Monthly, Get Ready Assist -Monthly $ 340.00 / Monthly, Med Mgmt 2 - External Pharmacy -Monthly $ 1100.00 / Monthly, Shower Assist 1 -Monthly $ 250.00 / Monthly. S2 stated that at around 3:20 PM on 2/22/26 Resident 1’s (R1’s) family came for visit R1 and they reported the room was not cleaned and R1 was wet and needed to be changed. The apartments was cleaned right away by staff and an internal investigation was conducted and it was found that Care partner, Staff 4 (S4), in the morning did not meet expectations of cleaning R1 and R1's room. S2 stated they were in a rush and neglected to complete cleaning for R1. As a result, R4 received corrective action and where removed from the schedule pending additional training. Additionally, on 2/24/26, a corrective action write up was given to Care Manger , Tonya Nepali (S3), whom was supposed to train all care staff, including S4, S3 was terminated. S2 stated, the apartment was not ”up to standard” as it was not cleaned; the room trash was not cleaned , and R1's Purewik device was not cleaned out. R1 uses an external catheter at night time and the facility is supposed to clean daily. [CONTINUED ON 9099-5] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Although a plan of correction was put in place prior in March 2026, it was reported that on 3/8/26 R1’s purewik external catheter was observed to not emptied out and cleaned until after 2:00PM on that day. S6 stated long wait times did occur of up to an hour or no response at all. It is possible that R1 was left sitting for hours in soaked and soiled briefs. It was alleged that a care staff advice whom no longer works at the facility would advise “doubling up” in which two diapers were used for R1, this would result in R1 getting irritations and pressure injuries. Staff are unaware of any staff advising to "double up". S1, S5, and S6 stated R1 preferred double padding and it was accommodated as it was the residents' preference but there was no "double briefing" as it is not allowed. Based on interviews and record reviews the allegation "Staff do not ensure incontinent needs are met" is substantiated. S5 stated that an interval investigation determined that Former Care Manger (S3) did not ensure to sufficient oversight over care staff. S7 (S7) was hired as of March 2026 as the new Care Manager in charge of oversight of care staff. Since starting, S7 is ensuring care staff calls button requesters are processed are responded to more thoroughly and that the facility is fully staffed and trained. In service training thus far include "Speak 2 Pendant Response" held on 3/21/26 and 3/25/26. Previously staff was able to clear calls before being with the residents, however the updated training requires staff i

According to the Suncrest Hospice Sacramento Certification and Plan of Care it indicates that Valium 5mg was prescribed to Resident #1 (R1) on 7/18/24 to take 1 tab orally once a day for muscle spasms which was discontinued on 7/19/24. LPA observed the Medication Administration Record (MAR) for July 2024 and Physician orders which contained changes to medication list. LPA observed that with PRNs the facility documentation has a comment section where staff would input a purpose for the PRN administration. After R1 returned to the facility on the evening of 7/18/24 from the hospital, R1 returned with medication changes. These medications were administered on 7/19/24 by facility staff and on 7/20/24 the Responsible Party was in possession of all R1s medication. In addition, facility conducts medication audits randomly and on every shift the narcotics are counted and logged as well as routine centrally stored medications are counted once received and sometimes randomly. LPA observed the narcotics count log which appears to show medication accounted for and logged. Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility mismanaged medication for R1. Regarding allegation, "Staff did not obtain a hospice care plan for resident" a review of resident file and hospice records revealed that R1 was admitted to Snowline Hospice on 5/24/24. Per the Case Conference Summary report dated 6/6/24 and 6/20/24 changes were made to the service plan and reassessment of eligibility was conducted. LPA observed that per the Patient Schedule R1 was transferred from Snowline Hospice to Suncrest Hospice on 7/18/24 where there was an initial visit by hospice staff, then 7/19/24 there were 3 follow-up visits, another visit on 7/20/24, and the last visit was conducted on 7/21/24 by a chaplain. Suncrest Hospice Skilled Nursing Visit Notes indicated that R1 Responsible Party gave preference regarding hospitalization and spiritual and all other concerns on 7/18/24. An interview with the Administrator revealed that R1 Responsible Party wanted to change hospice agencies from Snowline to Suncrest and initiated the change after which time the Licensee received the care plan from Suncrest and spoke with the RP regarding implementing the plan. Based on the process of receiving hospice services, traditionally, the resident may be declining, facility speaks with family and doctor, physician and hospice meet, then the RP and hospice meet to create a plan, then the facility and Responsible Party discuss it to ensure the plan can and will be implemented. Based on records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not obtain a hospice care plan. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding allegation, "Staff did not maintain a comfortable temperature for resident" LPA observed a work order for 6/5/24 which R1 Responsible Party stated the air conditioner was not working. A work order was created, however, when maintenance checked the unit the cold air button was not pushed as the unit was in working condition. LPA and Administrator conducted a unit test during this visit and the unit in the same room was operating correctly. An interview conducted with Staff #3 (S3) during todays visit revealed that the room units are replaced when broken, and service is conducted for common area units. Based on observation, records review and interviews, LPA did not observe a preponderance of evidence standard that facility did not maintain a temperature in the facility that is in accordance with the regulations. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. “This agency has investigated the complaint alleging the above mentioned allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.” Exit interview held, and a copy of todays’ report provided.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 99 Non-ambulatory residents of which 15 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 9 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and exit alarms in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 4 staff and 4 resident files during this visit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-(if applicable)Submit Infection Control Plan-Submit if applicable Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/17/24 at 12:00pm. LPA met with Kasie Wimmer and stated the purpose of todays visit. Administrator certificate expires 5/21/25. License fees are current. The facility is licensed for a capacity of 99 Non-ambulatory residents of which 15 may receive hospice care services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. There is 9 resident receiving hospice care services. The most recent emergency drill was conducted on 8/29/24. LPA observed 2-day perishables and 7-day non-perishables. Facility has required postings which include Oxygen in Use. The temperature thermostats inside was observed to be at 75*F throughout the facility which is within the required range of 68-85*F. The hot water temperature was measured 114.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air and exit alarms in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.

On 6/12/24 at 11:00am LPA Kevin Gould Conducted a POC clearance. LPA confirmed POC documentation for in service training. POC letter generated.