Autumn Ridge Assisted Living

87413(a)(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.This requirement is not met as evidenced by: Based on interviews and records reviewed, R1's current physician report documents that the R1 cannot leave the facility unsupervised. Interviews confirmed R1 had left the facility premises with R2 without staff supervision on 01/06/26, poses an immediate health and safety risks to persons in care.

Give PRN medication by physician order

Based on records review and observation, R4’s medication Metformin Hcl 500 mg and R3's medication Losartan was not administered as directed by physician, which poses an immediate health and safety risk for the person in care.

Record centrally stored prescriptions and refill data

Based on interview conducted, observation, and records reviewed, R3’s medication Atorvastatin 40 mg and Donepezil Hcl 5 mg were administered daily and not record in Centrally Stored Medication List (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Based on observation and records reviewed, R1 and R2 are on hospice care lying bed using a hospital bed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Dispose of unused medications with required witness

87465 (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction.This requirement is not met as evidenced by: Based on interview conducted and observations, medications for expired residents and discontinued medications were not record nor destructed backdating to March 2025, in which poses/posed a potential health and safety and personal rights risk to the resident in care.

Give PRN medication by physician order

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on interviews and records review, at approximately 03:30PM, S1 administered medication oxycodone-acetaminophen 10mg-325mg prescribed for R3 to R4 and at approximately 08:41PM, S1 administered medication hydrocodone-acetaminophen 5mg-325mg prescribed for R1 to R2, which poses an immediate health and safety risks to persons in care.

Store centrally held medications in locked secure place

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA toured the facility at approximately 10:27AM, observed one medication tablet on bedside tablet next to the resident unlock which poses an immediate health, safety or personal rights risk to person in care.

Resident care and supervision skills

87411(d)(3) Personnel Requirements – General All personnel shall be given on the job training…This training and/or related experience shall provide knowledge of and skill…by safe and effective job performance, Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.This requirement was not met: Based on observation and records reviewed, at approximately 01:37PM, LPA and Administrator observed resident call pendant not being responded by staff in a timely matter upon activation. Call log record total average staff responds to residents’ call in one day is above 49.78 minutes from 04/01/25 to 04/16/25, which poses a potential health and safety and personal rights risk to the person in care.

Maintain fire clearance before retaining specified persons

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA arrived at the facility the front automatic door was locked, which poses/posed an immediate health, safety or personal rights risk to persons in care.

Food storage temperature control requirements

87555 (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.This requirement is not met as evidenced by: Based on interviews conducted, observation, and records reviewed, the facility did not have a working freezer for over two weeks to store frozen food, which poses/ posed a potential health and safety risks to persons in care.

Give PRN medication by physician order

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on interviews and records review, on 09/18/24, R1’s medications were not administered to the resident and was put on hold. R1's medications was placed on hold by S1 without a doctor’s order on 08/25/24. On 10/22/24, S2 administered R5’s medication Lorazepam 1 mg to R2. On 10/24/24, S4 administered R4’s medication Hydralazine HCL 25mg to R3, which poses an immediate health and safety risks to persons in care.