AUTUMN RIDGE ASSISTED LIVING

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Fire Extinguisher throughout the facility has a service date of 06/13/25, which poses an immediate health and safety risk to the residents.

Official plan of correction

POC Due Date: 07/15/2026 Plan of Correction All fire extinguishers shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 07/15/26.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

HSC 1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed and interview, S1 do not have current First Aid and CPR certification, this poses an immediately health and safety risk for the residents in care.

Official plan of correction

POC Due Date: 07/15/2026 Plan of Correction Proof of S1 current First Aid and CPR certification is to be submitted to the Fresno CCL by 07/15/26.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(A) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to required other additional documentation if needed to verify the order. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This was not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, R1 has a half rail bed with no doctor’s order, in which poses/posed an potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 07/24/2026 Plan of Correction Doctor orders for R1 for half rail bed shall be obtained or half rail shall be removed by POC due date 07/24/26.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

87303(e)(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when bedroom room 301 and room 303 was observed with no non-skid mat or strip in the bathroom showers, which poses/posed a potential health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 07/20/2026 Plan of Correction Proof of non-skid mat or strips placed in bathrooms shower shall be submitted to the Fresno CCL by POC due date 07/20/26.

Official classification

Type A

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Facility shall submit a plan detailing steps the facility will take to ensure the requirements are met by 01/13/26.

Deadline recorded: Jan 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction All medication technicians will be re-trained on medications trainings. Documentation of training topics and materials with staff attendance rooster will be submitted to Fresno CCL by POC due date 06/18/25.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year… This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction R3’s medications shall be recorded in Lic 622 and submitted to the Fresno CCL by POC due date 06/20/25.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 06/23/2025 Plan of Correction Full bed rails are prohibited. Licensee shall obtain doctor orders for R1 and R2 that specific the need for half bed rails and remove full bed rails by POC due date 06/23/25.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

All medications to be disposed shall be destroyed and recorded. Administrator will submit documentation of steps facility will take to ensure disposed medications are record and destroyed properly and timely to Fresno CCL by POC due date 06/18/25.

Deadline recorded: Jun 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Staff immediately removed medication from resident’s room.

Deadline recorded: May 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

S1 was terminated on 04/23/25. All medication technician staff will have in-serviced training which will also include administering medications. Licensee will submit documentation of training topics and attendance roster to the Fresno CCL office by POC due date 05/22/25.

Deadline recorded: May 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will have in-service training for all staff regarding answering residents pendant alert call in a timely matter. Documents of staff in-service training and rooster of attendance shall be submitted to Fresno CCL by due date 04/29/25.

Deadline recorded: Apr 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator immediately unlocked the front door. POC cleared during visit.

Deadline recorded: Mar 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Facility has a new freezer that arrived on 03/11/25 and not being put in use to store frozen food. New freezer will be plug in and utilized by POC due date.

Deadline recorded: Mar 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

S1, S2 and S4 was retrained on medications regulation which will include administering medications. Copies of trainings materials and proof of staff retrained will be submitted to department by 11/08/24.

Deadline recorded: Nov 8, 2024. A deadline is not proof that correction was completed.