Karlton Residential Care Center

Care and supervision as defined by statute and rules

87464(f)(1) “Basic services shall at a minimum include: Care and Supervision” This requirement was not met as evidenced by: Based on record review, interviews, and observations, the facility failed to provide adequate Care and supervision and follow-up interventions for R1, who sustained multiple falls, including a hip fracture and femur fracture, without corresponding changes in their supervision plan or care strategy. This lack of supervision posed an immediate health and safety risk to residents in care.

87211(a)(1)(D)"licensee shall furnish to the licensing agency such reports as the Department may require, including Any incident which threatens the welfare, safety or health of any resident" Based on record search of CCL SIR portal system the facility did not report incidents involving R1 that threatened the resident’s health and safety: nine repeated fall resulting in at least two fractures between November 2023 and December 2024. The facility’s failure to submit the required incident reports posed a potential health and safety risk to residents in care.

87463(b)(1)(E) ".Appraisal, shall be updated in writing as frequently as necessary" Based on record review, the facility did not update R1’s Needs and Services Plan following significant changes in condition, including nine falls resulting in two fractures between November 2023 and December 2024. The Needs and Services Plans dated May 18, 2023, May 18, 2024, and March 10, 2025, did not include individualized supervision requirements or interventions necessary to address R1’s fall risk needs. This posed an immediate health and safety risk to residents in care.

Arrange appropriate medical and dental care

87465(a)(1)"licensee shall arrange, or assist in arranging, for medical care appropriate to the conditions and needs of residents"Based on record review, the facility did not ensure that R1 received timely medical attention following a change in condition. On December 17, 2024, R1 sustained a fracture of the distal left femur; however, R1 did not receive an x-ray diagnosing the fracture until approximately 10 days after initial swelling. This posed an immediate health and safety risk to residents in care

If the resident leaves the facility for any reason during the first month of residency, the resident shall be entitled to a refund of at least 80 percent of the preadmission fee amount in excess of five hundred dollars ($500). This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure resident/ responsible party received a refund for 80 percent of preadmission fee. This poses a potential health and safety risk to residents in care.

Care and supervision as defined by statute and rules

Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Codesection 1569.2(c). This requirement is not being met as evidenced by: Based on interview and record review, Licensee failed to ensure R1 was provided care and supervision. R1 eloped out of the facility and was discovered by Starbucks staff approximately .9 miles away. This poses an immediate health and safety risk to residents in care.