Health inspection·October 27, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify the Responsible Party (RP- the person who is responsible for making health care decisions for a resident) of falls and a change of condition for one of two residents (Resident 1) sampled for falls, when Resident 1 had four unwitnessed falls, her indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) fell out and was not replaced, a change in condition due to a head injury, was transferred to an emergency department (ED) and the RP was not notified.Refer to F689.This failure prevented the family from knowing about Resident 1's falls, condition changes, and transfer to the emergency department, hindering their ability to make informed decisions and participate in Resident 1's care.Findings.A review of the facility's policy titled Change in Condition dated 8/25/22 indicated A Licensed nurse will notify the resident's Physician/APP (advanced practice providers) and legal representative or an appropriate family member when there is an: a. Incident/accident involving the resident: b. An accident involving the resident which results in injury and has the potential for requiring physician intervention; c. A significant change in the resident's physical, mental or psychosocial status. g. A decision to transfer or discharge the resident from the facility. The Licensed Nurse will notify the family/surrogate (an RP) decision-maker of any changes in the resident's condition as soon as possible.A review of Resident 1's admission Record dated 8/13/25, indicated Resident 1 was admitted to the facility from a local hospital on 8/13/25 with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (a respiratory disease that easily spreads to other people), difficulty in walking, muscle weakness, cognitive communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. Resident 1's RP and Emergency contact #1 was Daughter A.A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of 8/20/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's August 2025's Physician Orders indicated an order dated 8/13/25 which included: Resident is unable to make healthcare decisions.A review of Resident Page 1 of 14 056074 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1's Durable Power of Attorney for Health Care (legal document that allows you to name a person to make medical treatment decisions for you if you cannot, an RP) dated and signed by Resident 1 on January 25, 2001, indicated that Resident 1's husband was designated and appointed to make health care decision for Resident 1. If Resident 1's husband was unable to act as her agent, then Resident 1's two daughters (Daughter A and Daughter B) are to serve as her decision maker for health care.A review of Resident 1's Progress Note titled N Adv - Post Fall Evaluation dated 8/13/25 at 10:30 pm, Licensed Vocational Nurse (LVN) B documented Time of Fall 8/13/25 9:45 pm. Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to brush her teeth. Resident 1's post fall risk score was 7 (at risk for falls). Resident's responsible party notified: Yes. Person contacted: Resident is her own RP. A review of Resident 1's Progress Note titled Alert Note dated 8/14/25 at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out. The indwelling catheter was not replaced. There was no documentation indicating the RP was notified.A review of Resident 1's Progress Note titled Social Service on 8/15/25 at 3:57 pm, Social Service (SS) documented Resident (1) request daughter, (name, Daughter A), to be her RP since her daughter is taking care of everything for herA review of Resident 1's Progress Note titled N Adv-post Fall Evaluation dated 8/19/25 at 01:05 am, concerning fall at 8/19/25 at 0:55 am, LVN B documented Unwitnessed fall responsible party notified: Yes, Person Contacted: Resident is her own RP.A review of Resident 1's Progress Note titled N Adv-post Fall Evaluation dated 8/19/25 at 9:10 pm, concerning fall at 8/19/25 at 9:00 pm, LVN B documented Unwitnessed fall responsible party notified: Yes, Person Contacted: Resident is her own RP.A review of a Progress Note titled eINTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated 8/20/25 at 1:30 pm, RN A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, BP=174/122 (normal is less than 120/80) altered level of consciousness and increased confusion potential signs of a head injury and/or brain bleed. Primary provider was notified and ordered to send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment. No documentation that the RP was notified of transfer to ED.A review of the ED provider notes from the local hospital dated 8/20/25 at 2:12 pm, indicated that Resident 1 arrived at the hospital on 8/20/25 at 2:12 pm.A review of Resident 1's progress notes titled Alert Note on 8/20/25 at 5:27 pm, RN A documented Called residents daughter (name of Daughter A), left voicemail message requesting return phone call to touch base about recent events and further plan of care. Three hours after Resident 1 arrived at the ED.During a phone interview with Daughter 1 on 10/2/25 at 3:59 pm, Daughter 1 stated that she had not been notified about Resident 1's indwelling catheter falling out and not being replaced, Residents 1's falls, and that she went to the ED on 8/20/25. Daughter 1 said that her father (Resident 1's husband) was in the hospital due to an illness and that the facility was informed on 8/15/25 to call her (Daughter 1) for any changes in condition but they failed to do so. Daughter 1 indicated she also had an illness that prevented her from going to the facility and was unable to visit Resident 1 so she relied on the facility to keep her informed of changes with Resident 1.During an interview on 10/21/25 at 2:02 pm, RN A stated that there was some confusion, as to who was Resident 1's RP.During an interview on 10/22/25 at 12:44 pm, LVN B stated that she did not call family when Resident 1 had her fall on 8/13/25 and her two falls 8/19/25 because her admission Record at those times indicated that Resident 1 was her own RP.During a concurrent interview with RN A and record review on 10/22/25 at 2:56 pm, Resident 1's Progress Notes titled Alert Note dated 8/14/25 at 11:28 am, was reviewed. RN A stated that when Resident 1's 056074 Page 2 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling catheter fell out, the physician informed her not to replace the catheter. RN A confirmed that there was no documentation concerning the family or RP being notified concerning the discontinuation of the indwelling catheter and as per the facility policy.During a concurrent interview with the Director Of Nursing (DON), on 10/2/25 at 3:55 pm, Resident 1's Progress Note titled Social Service on 8/15/25 at 3:57 pm was reviewed. DON confirmed that Daughter A wanted to be notified of any changes in Resident 1's condition and was not sure why she wasn't. 056074 Page 3 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an injury of unknown origin and major accident for one of two residents (Resident 1) sampled for falls, was reported to the California Department of Health (CDPH) when Resident 1 had a bruise and bump on her head of unknown origin, unwitnessed falls, and a change in condition which sent Resident 1 to the hospital and eventually die due to a brain bleed.This failure to report had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse.FindingsA review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting dated [DATE], indicated The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies (California Department of Health, CDPH) c. Other Occurrences. ii. Major accidents. iv. Other occurrences that. affect the welfare, safety, or health of residents. Unusual occurrences are reported to the appropriate agency withing 24 hours by telephone and confirmed in writing.A review of Resident 1's admission record dated [DATE], indicated Resident 1 was admitted to the facility from a local hospital on [DATE] with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee.A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of [DATE], Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's Progress Notes titled IDT (Interdisciplinary Team, a group of professionals to address complex problems) Progress Notes- Falls dated [DATE] at 7:23 am, IDT clinical team documented a review of Resident 1's unwitnessed. fall on [DATE] at 5:10 am. Per resident input, I fell and hit my head on the door'. ‘I don't know what happened, I just fell.'A review of Resident 1's Progress Notes titled Alert Note by Licensed Vocational Nurse (LVN) B on [DATE] at 00:55 am, the note indicated that Resident 1 had another unwitnessed fall.A review of Resident 1's Progress Note titled Alert Note by LVN B on [DATE] at 9:10 pm, the note indicated that Resident 1 had another unwitnessed fall.A review of a Progress Note titled eINTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated [DATE] at 1:30 pm, Registered Nurse (RN) A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, BP=174/122 (normal is less than 120/80) altered level of consciousness and increased confusion potential signs of a head injury and/or brain bleed. Primary provider was notified and ordered to 056074 Page 4 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment.A review of the Ambulance report dated [DATE] at 2:30 pm, Paramedic (PM) documented female sitting in her wheelchair complaining of a headache secondary to a fall 5 days ago. Staff report patient has fallen 4 times in the last 5 days. Pt experienced a head strike with the first fall 5 days ago. Staff report patient has become more altered today and began complaining of a splitting headache. Small contusion (bruise) to forehead .A review of the local hospitals report dated [DATE] by Medical Doctor (MD), MD documented Over the last few days has had multiple falls with one known head strike. Is normally oriented x 4 but today was found to be oriented x 1 only and is confused. She is complaining of a headache. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS (central nervous system, brain and spinal cord, which act as the body's main control center) failure or compromise.A review of the local hospital's CT (computerized tomography, a type of X-ray) of the head without contrast (no dye was used) was done and the final result dated [DATE] at 3:15 pm, was read by Radiologist (RD), RD indicated Extensive subdural (a life-threatening large volume of bleeding in the outermost covering of the brain, most commonly caused by a severe head injury, but can also occur with minor trauma, especially in older adults and symptoms can develop days or weeks after an injury) and intraparenchymal hemorrhage(a bleed directly into the brain's functional tissue) in the left cerebral (brain) hemisphere with tiny focus of subarachnoid hemorrhage ( SAH, small bleed in the area between the brain and its middle protective membrane. Traumatic brain injury is a common cause of SAH) in the right frontal lobe and tiny focus subdural hemorrhage (small bleed on the right side of the brain) adjacent to the right frontal lobe. Localized mass effect (large amount of blood) in the left parietal (upper-back and rear areas of the brain) and occipital lobe (primary visual processing center of the brain) secondary to the large hematoma (bleed). A review of Resident 1's Death Certificate dated [DATE], indicated Resident 1 died on [DATE] and the cause of death was subdural hematoma from a mechanical (falls caused by external or environmental factors, slipping or tripping) fall. Injury occurred at the Facility (name) and was due to an unwitnessed fall causing subdural hematoma.During a concurrent interview with RN A and record review on [DATE] at 2:02 pm, Resident 1's progress note created on [DATE] as a late entry for the date of [DATE], by RN A was reviewed. RN A stated that on [DATE] at around 1:00 pm, the social service assistant approached her and stated that Resident 1 was not acting right. RN A stated that she assessed Resident 1 and she was holding her hands over her eyes, with eyes closed and a grimaced expression. Resident 1 stated she had a headache but could not give description of pain or pain source. RN A stated that Resident 1 had a bump with discoloration (bruise) on her forehead and it measured 21mm (millimeters, a measurement of about an inch). The Physician was notified and recommended sending Resident 1 to the acute care setting for further evaluation and treatment.During an interview with the Director of Nursing (DON) on [DATE] at 3:26 pm, DON confirmed that the facility did not report this accident or bruise of unknown origin to the CDPH because Resident 1 went to the hospital and did not come back to their facility. 056074 Page 5 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of two residents (Resident 1) sampled for falls. Resident 1 had four unwitnessed falls in seven days, three occurring after an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) was not replaced and contributed to Resident 1's falls by her attempting to toilet herself. Key failures included:Care Plan was not updated with new interventions to prevent further falls, despite the facility's fall policy requiring increased observation and structured routine for residents with two or more falls in a week.Nurses had not completed the required assessments, the Neurological (refers to brain, nerves and spinal cord function) Flow Sheet (a standardized document used by healthcare professionals to record and monitor a patient's neurological status over time. This tool is crucial for detecting subtle changes or a sudden deterioration in a patient's condition, especially in cases of head trauma that results in a brain bleed), for 72 hours after an unwitnessed fall, and the alert charting (nursing documentation once a shift concerning the status of a resident after a fall) for 72 hours, to determine if Resident 1 had a head injury and had not recognized when she showed signs of a brain bleed (signs of a brain bleed include: headache, confusion, difficulty in thinking, weakness of one side of the body and loss of balance and coordination.No bladder assessment or individualized toileting program (staff track the resident's bathroom habits over several days to identify patterns in urination) was done after the catheter came out.This resulted in repeated falls for Resident 1 and subsequently, a head injury that developed into a brain bleed that required hospitalization and resulted in the death of Resident 1.Findings:A review of the facility's policy and procedure (P&P) titled Fall Management Program revised [DATE], indicated it is the facility's purpose to provide a safe environment that minimizes complications associated with falls. The P&P indicated that the Licensed nurse and/or IDT (Interdisciplinary Team, a group of professionals to address complex problems) will develop a Plan of Care according to the identified risk factors and root cause. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment and update, initiate or revise a Plan of Care. The Licensed Nurse will complete the Neurological Flow Sheet for an un-witnessed fall. for seventy-two hours following the fall incident. Within 15-20 minutes after a fall the Licensed Nurse will initiate a post fall huddle utilizing the Post fall Huddle form. Once the post fall huddle is completed the Licensed Nurse will update the care plan with immediate recommendations. A resident who sustains multiple falls as defined as more than one fall in a day, week. will be considered a high risk to fall and as a result may sustain a major injury. These residents may: require more frequent observation of activities and whereabouts, may require a structured environment or routine, and may require special equipment to promote independence. These interventions will be documented on the resident's plan of care and in the resident's clinical record.A review of the facility's Fall Incident Checklist (undated), indicated that after a resident has a fall the staff is to place resident on alert charting for 72 hours, initiate frequent safety checks and implement a new intervention in the long-term care plan.A review of the facility's policy and procedure (P&P) titled Bowel and Bladder Indwelling Catheter -Insertion, Maintenance and Discontinuation of revised [DATE], indicated Discontinuation of an Indwelling Catheter. D. Bladder training (a therapy that aims to improve bladder control and uses scheduled urination timetable to help gain control of urination) will be provided as indicated per the Bowel and Bladder Training/Toileting Program. F. The residents' care plan will be updated as necessary.A review of the facility's P&P titled Bowel and Bladder 056074 Page 6 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few Training/toileting Program revised [DATE], indicated, The licensed nurse will assess a Resident's bowel and bladder status.upon the removal of an indwelling catheter. Interventions identified by the licensed nurse and or the IDT will be care planned and communicated to the corresponding professional and to the facility staff for implementation. Following review and determination for the residents voiding (urinating)/bowel evacuation pattern, the licensed nurse will develop an individualized Bowel and Bladder Training Program to meet the Resident's needs. The established pattern and individualize bowel and bladder training intervention (s) will be documented in the care plan. A review of Resident 1's admission record dated [DATE], indicated Resident 1 was admitted to the facility from a local hospital on [DATE] with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of [DATE], Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and continent with her bowel movements.A review of Resident 1's Hospital record titled Physical Therapist (PT) Therapy Daily/Treatment dated [DATE], PT documented discharge recommendation: 24-hour supervision/assist. A review of Resident 1's [DATE]'s Physician Orders indicated orders dated [DATE] which included medications that increased her risk for falls, frequent toilet needs and increased bleeding. Furosemide (a water pill that helps reduce fluid in the body through urination and caused Resident 1's increased risk for falls due to her frequent toilet needs) 20 mg (milligrams a measurement) daily. Rivaroxaban (a medication that prevents blood from clotting and increases the potential for bleeding and bruising) 15 mg daily. Resident is unable of making healthcare decisions.A review of Resident 1's Fall Care Plan dated [DATE], indicated, The Resident is at risk for falls related to deconditioning (the decline in physical and mental function), gait (the pattern how a person walks) balance problems, weakness interventions included: Call light is within reach and resident needs prompt response to all requests. Educate the resident about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear when ambulating or moving in wheelchair (w/c). Follow facility fall protocol. Physical Therapy to evaluate and treat as ordered or PRN (as needed). Fall 1:A review of Resident 1's Progress Notes titled Alert Note dated [DATE] at 9:55 pm, Licensed Vocational Nurse (LVN) B indicated Resident 1 was found to be yelling out for help. Resident 1 was found sitting on the floor in front of her closet.A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 10:30 pm, LVN B documented fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to brush her teeth. Resident 1's post fall risk score was 7 (at risk for falls).A review of Resident 1's 056074 Page 7 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few Progress Notes titled IDT Progress Notes - Falls dated [DATE] at 7:23 am, the IDT clinical team documented the review of Resident 1's unwitnessed non-injury fall on [DATE] at 9:45 pm. During rounds resident was heard yelling out for help. Upon staff investigation, resident was seen sitting on the floor in front of her closet, wearing non-skid socks. Per (by means of) resident input, Resident stated, ‘I was going to go brush my teeth and sat on the floor when I lost my balance.' Root cause of fall for Resident 1 was documented as adjusting to new facility and most likely adjusting to required supervision/SBA (stand by assist) for ADL's (activities of daily living, like brushing teeth, washing face, transferring to bed or wheelchair, walking and toileting) and probably not thinking she needed help. IDT rec (recommendation) is MRR (medication regimen review), continue with therapy evaluation for strengthening and safety transfers.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention (for the [DATE] fall) on [DATE] indicating to continue with therapy evaluation for strengthening and safety transfers. The care plan had not included assisting Resident 1 with brushing her teeth.A review of Resident 1's Progress Notes titled Alert Note dated [DATE] at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out and was not replaced. A review of Resident 1's [DATE] progress notes indicated there was no documentation in Resident 1's progress notes to indicate why the indwelling catheter was not replaced. A review of Resident 1's [DATE] Physician Orders indicated there was no order to discontinue the indwelling catheter. A review of Resident 1's [DATE] Care Plans indicated there was no Bowel and Bladder Care Plan developed and no individualized Bowel and Bladder Training Program to meet Resident 1's bladder needs, since she would then have to use the toilet instead of a urinary catheter to empty her bladder.Fall 2:A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 5:10 am, LVN C noted Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of the fall. Resident 1's post fall risk score was 14 (at high risk for falls).A review of Resident 1's Progress Notes titled IDT Progress Notes- Falls dated [DATE] at 7:23 am, IDT clinical team documented a review of Resident 1's unwitnessed. fall on [DATE] at 5:10 am. Per resident input, I fell and hit my head on the door'. ‘I don't know what happened, I just fell' root cause of fall is adjusting to new facility, same root cause as Fall number one. IDT indicated Resident 1's indwelling catheter had been discontinued and there was no documented discussion about a toileting program for Resident 1.A review of Resident 1's Neurological Flow Sheet dated [DATE] starting at 5:10 am, indicated an incomplete flow sheet with no assessment of level of consciousness (ability to think clearly), movement (balance and coordination), hand grasps (determines if there is a weakness for one side of the body), pupil size (a sudden change in pupil size can be a sign of a brain bleed) and reaction for the first 24 hours.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] for orthostatic blood pressure (dropping of blood pressure that occurs when a person stands up from sitting or lying position) evaluation. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week. A review of Resident 1's Nursing Progress Notes/Alert Charting from [DATE] to [DATE] indicated that between [DATE] at 7:45 am, to [DATE] at 6:24 pm, for 82 hours, there was no shift (every eight hours) alert charting, for the required 72 hours after a fall, concerning Resident 1's condition after the [DATE] fall at 5:10 am.A review of Speech Therapy Evaluation and Plan of Treatment dated [DATE] at 6:13 pm, by Speech Language Pathologist (SLP), SLP documented However, due to the patient's high level of pain (10/10) and multiple attempts to complete the assessment, ST discontinued the session and discussed with patient that it will be completed during the next 056074 Page 8 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few treatment session. ST continued to document PT (patient) requires 24/7 supervision and is a high fall risk. A review of Resident 1's [DATE]'s MAR indicated that on [DATE] at 6:35pm, Resident 1 complained of a headache rating a pain level of 6 (on a scale of 0-10, where 0 is no pain and 10 is the worst pain, one could experience). Resident 1 was given Tylenol 650 mg for moderate to severe pain. LVN B documented a follow up charting on [DATE] at 8:24 pm, indicating the Tylenol was ineffective and Resident 1's pain level was now a 5. No physician follow up documented.Fall 3:A review of Resident 1's Progress Note titled Alert Note by LVN B on [DATE] at 00:55 am, LVN B documented This resident was heard asking for help, upon arrival the resident was found to be sitting on the floor with her back against the bed. When asked what happened the resident stated that she was attempting to go back to bed from the bathroom but fell on the floor before sitting on the bed.A review of Resident 1's Progress Notes titled, IDT Progress Notes- Falls dated [DATE] at 8:26 am, IDT documented IDT clinical team review of unwitnessed non-injury fall [DATE] at 00:55 am. Root cause of fall was resident not requesting assistance with toileting need. IDT recommended is MRR, continue with therapy as ordered and therapy to post safety reminders to ask for help. Resident 1's need for toileting assistance or individualized toileting program, was not addressed.There was no Neurological Flow Sheet for Resident 1 for the date of [DATE] at 00:55 am for fall # 3 as per policy for an unwitnessed fall. This was confirmed by the Medical Records (MR) on [DATE] at 2:30 pm. A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] to continue with therapy as ordered. There were no interventions for frequent observation of activities and whereabouts, and a structured environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week or individualized toileting program.A review of Resident 1's [DATE]'s MAR indicated that on [DATE] at 1:53 pm, Resident 1 complained of unidentified pain rating at a 5 and Tylenol 650 mg was given for pain. Follow up charting on [DATE] at 5:08 am, LVN B documented it was unknown if the Tylenol was helpful. A review of the Physical Therapy Treatment Encounter Note dated [DATE] at 2:53 pm, Physical Therapy Assistant (PTA), PTA documented Standing balance at sink for basic ADL's, w/ (with) low tolerance as pt (patient) presents with a headache. A review of the Occupational Therapy Treatment Encounter Notes dated [DATE] at 5:09 pm, by Occupational Therapy (OT), OT documented Response to session interventions: Pt (patient) presents extremely disoriented this date, pt (patient) repeatedly stated she did not feel well. Fall 4A review of Resident 1's Progress Note titled, Alert Note by LVN B on [DATE] at 9:10 pm, LVN B documented During med pass the resident was heard faintly asking for help. LN responded and noticed the resident was lying on her left side on the floor at the foot of her bed. A review of Resident 1's Progress Notes titled N Adv - Post Fall Evaluation dated [DATE] at 9:10 pm, LVN B documented Time of fall [DATE] at 9:00 pm, fall was not witnessed and occurred in resident room. Resident was attempting to self-toilet (go to the bathroom by herself) at time of fall. Fall risk score 19 (at high risk for falls).A review of Resident 1's IDT Progress Notes- Falls dated [DATE] at 7:21 am, IDT documented IDT clinical team review of 2nd unwitnessed non-injury fall on 8/19 at 9:00 pm. Root cause of fall is possibly that resident continues at this time adjusting to new environment and possibly adjustment to requiring assistance with care and remembering to request assistance. IDT recommends is MRR, continue with therapy for strengthening/safety transfers and continue with ST (Speech Therapy) for cognition (mental status).There was no Neurological Flow Sheet for Resident 1 for the date of [DATE] at 9:10 pm for fall #4. This was confirmed by MR on [DATE] at 2:30 pm.A review of Resident 1's [DATE] Fall Care Plan indicated one updated intervention on [DATE] for therapy to post safety reminders to ask for help. There were no interventions for frequent observation of activities and whereabouts, and a structured 056074 Page 9 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few environment or routine, or special equipment to promote independence as per their Fall Management Program policy when there were two or more falls in a week or individualized toileting program. A review of a Progress Note titled e-INTERACT (Interventions to Reduce Acute Care Transfers, a clinical decision support tool) SBAR (Situation, Background, Assessment, Recommendation, a communication framework used to exchange information between healthcare professional) for a change in condition, dated [DATE] at 1:30 pm, Registered Nurse (RN) A indicated that Resident 1 had a change in condition which was due to abnormal vital signs, blood pressure of174/122 (normal is at or less than 120/80) altered level of consciousness (a decrease in alertness, awareness and responsiveness) and increased confusion. Primary provider was notified and ordered to send Resident 1 to the acute care setting (local hospital) for further evaluation and treatment.A review of the Ambulance report dated [DATE] at 2:30 pm, Paramedic (PM) documented, female sitting in her wheelchair complaining of a headache secondary to a fall 5 days ago. Staff report patient has fallen 4 times in the last 5 days. Pt experienced a head strike with the first fall 5 days ago. Staff report patient has become more altered today and began complaining of a splitting headache. Small contusion (bruise) to forehead.A review of the local hospital's report dated [DATE] by Medical Doctor (MD), MD documented, Over the last few days has had multiple falls with one known head strike. Is normally oriented x 4 (person, place, time, and situation) but today was found to be oriented x 1 (person) only and is confused. She is complaining of a headache. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS (central nervous system, brain and spinal cord, which act as the body's main control center) failure or compromise.A review of the local hospital's CT (computerized tomography, a type of X-ray) of the head was done and the final result dated [DATE] at 3:15 pm, was read by Radiologist (RD), RD indicated, Extensive subdural (a life-threatening large volume of bleeding in the outermost covering of the brain, most commonly caused by a severe head injury, but can also occur with minor trauma, especially in older adults and symptoms can develop days or weeks after an injury) and intraparenchymal hemorrhage(a bleed directly into the brain's functional tissue) in the left cerebral (brain) hemisphere with tiny focus of subarachnoid hemorrhage ( SAH, small bleed in the area between the brain and its middle protective membrane. Traumatic brain injury is a common cause of SAH), in the right frontal lobe and tiny focus subdural hemorrhage (small bleed on the right side of the brain) adjacent to the right frontal lobe. Localized mass effect (large amount of blood) in the left parietal (upper-back and rear areas of the brain) and occipital lobe (primary visual processing center of the brain) secondary to the large hematoma (bleed). A review of Resident 1's Death Certificate dated [DATE], indicated Resident 1 died on [DATE]. The cause of death was subdural hematoma caused by an unwitnessed fall at [Facility name].During a concurrent interview with the Director of Rehabilitation (DOR) and a record review on [DATE] at 11:45 am, Resident 1's Fall Care Plan was reviewed. DOR stated that Resident 1 required moderate assistance with staff for transferring, toileting and walking. The DOR stated that there were no adequate interventions after each fall, like increase supervision or use a fall mat by bed, to protect Resident 1 from falls and injuries and there should have been.During a concurrent interview with RN A and record review on [DATE] at 2:02 pm, Resident 1's progress note created on [DATE] as a late entry for the date of [DATE], by RN A was reviewed. RN A stated that on [DATE] at around 1:00 pm, the social service assistant approached her and stated that Resident 1 was not acting right. RN A stated that she assessed Resident 1 and she was holding her hands over her eyes, with eyes closed and a grimaced expression. Resident 1 stated she had a headache but could not give description of pain or pain source. RN A stated that Resident 1 had a bump with discoloration on her forehead and it measured 21mm (millimeters, a measurement of 056074 Page 10 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few about an inch). The Physician was notified and recommended sending Resident 1 to the acute care hospital for further evaluation and treatment. RN A stated that with every unwitnessed fall the staff were supposed to perform neuro checks and every 8 hours and alert charting for 72 hours to evaluate a resident's condition after a fall, because they were assessing for a head injury. RN A was unable to provide documented alert charting or completed neuro checks for Resident 1 after fall number two on [DATE] and fall number three and four on [DATE]. RN A confirmed that they should have been done.During a concurrent interview with LVN E and record review on [DATE] at 3:02 pm, Resident 1's [DATE]'s Medication Administration Record (MAR) was reviewed. LVN E stated that Resident 1 was weak, had COVID and was in isolation (requiring a private room). Resident 1 would not use her call light. She would just get up and go (to the bathroom). She was supposed to have someone go with her. LVN E stated that hourly safety checks should have been done for Resident 1 due to her falls and condition, if hourly safety checks were done for a resident they would have been documented on the MAR. A review of Resident 1's MAR indicated that there were no hourly safety checks documented for Resident 1. During an interview with LVN B on [DATE] at 12:44 pm, LVN B stated that Resident 1 was confused, unstable, had a UTI and was getting up and down to the bathroom a lot. LVN said that after Resident 1's indwelling catheter came out she was going to the bathroom every 1-1/2 to 2 hours. LVN B stated that Resident 1 had fallen three times during her shifts out of the total of her four falls. LVN B recalled that when Resident 1 felt the urge to urinate, she would get up and go and would not use the call light to ask for assistance. LVN B stated that when there was enough staff scheduled, she had a staff member sit outside of Resident 1's room to increase Resident 1's supervision and assistance with toileting. LVN B said there was not always enough staff to do this. LVN B stated that she felt Resident 1 should have had a one on one intervention (meaning a staff member was assigned to Resident 1 all the time) in her Fall Care Plan to prevent her from falling. LVN B confirmed she did not put any new interventions into Resident 1's fall care plan concerning Resident 1's need to be a one on one. LVN B stated she did not know how to make care plans, and she needed training on this.During an interview with Certified Nursing Assistant (CNA) F on [DATE] at 1:27 pm, CNA F stated that Resident 1 would walk back and forth to the bathroom, not put her call light on, and would always shut her door to her room and needed to be checked on frequently.During an interview with CNA G on [DATE] at 2:13 pm, CNA G stated that Resident 1 was a high fall risk, and got up a lot without her walker, was in an isolation room and would not use her call light for help. CNA G stated that there were no special instructions about when to check on her.During a concurrent interview with the Director of Nursing (DON) and record reviews on [DATE] at 3:55 pm, Resident 1's [DATE] Progress Notes (which included the alert charting), Fall Care Plan, Physician Orders and Neurological Flow Sheets were reviewed. DON confirmed that Resident 1 was in the facility for seven days and had four unwitnessed falls, including one with a head strike, during that time. DON confirmed that Resident 1's indwelling catheter fell out and was not replaced even though there was not a Physician order to discontinue it. DON reviewed Resident 1's care plans and confirmed that there had been no bladder training to assist Resident 1 with bladder control and there should have been as per their policy. DON stated that Resident 1 had hit her head on the second fall ([DATE]) and after the DON reviewed Resident 1's Neurological Flow Sheet, Progress Notes and Care Plans, she confirmed that the [DATE] Neurological Flow Sheet had not been completed, no alert charting had been done for 72 hours, and no new interventions were put into place to prevent Resident 1 from falling again as per the Fall Management Policy. DON confirmed that on [DATE] Resident 1 had two falls and there were no Neurological Flow Sheets completed, no alert charting for 72 hours and no new fall interventions were developed to prevent future falls as per 056074 Page 11 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0689 Level of Harm - Actual harm policy. DON stated that the interventions that should have been developed and implemented, to prevent falls, should have been to check resident before and after meals, and at bedtime for toileting needs and to monitor bowel and bladder needs every 2 hours after the indwelling catheter fell out and was not replaced. DON stated that a one-on-one intervention for supervision is only done as a last resort to prevent falls. Residents Affected - Few 056074 Page 12 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was admitted with an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag), had care and services to maintain normal bladder function when Resident 1(‘s): Did not have an assessment for the need of an indwelling catheter. Indwelling catheter was discontinued without a physician's order. Was not provided bladder training to restore normal bladder function after the indwelling catheter was removed. Did not have a care plan created with interventions concerning her bowel and bladder function.These failures caused Resident 1 to get up and down to the bathroom many times without assistance and have multiple falls.Findings:A review of the facility's policy titled Nursing Policy and Procedure (P&P)- Bowel and Bladder, Indwelling Catheter - insertion, maintenance and Discontinuation of. revision date of 7/22/25, indicated, A Licensed Nurse will assess the need for continued use of a catheter. The Licensed Nurse will notify the physician if the assessment indicates the need to discontinue catheter use and obtain orders. Bladder training (a therapy that aims to improve bladder control and uses scheduled urination timetable to help gain control of urination) will be provided as indicated per the Bowel and Bladder training/Toileting Program. The licensed nurse will monitor for any signs or symptoms of urinary burning, frequency, urgency, or suprapubic pain after the removal of the indwelling catheter and inform the physician for orders if noted or reported. The resident's care plan will be updated as necessary. A review of the facility's policy and procedure (P&P) titled Bowel and Bladder Training/Toileting Program revised August 21, 2020, the P&P indicated After the removal of a urinary catheter (indwelling catheter), services are provided to restore or improve bladder function to the furthest extent possible. The P&P continue to indicate: The licensed nurse will assess a Resident's bowel and bladder status. upon the removal of an indwelling catheter. Interventions identified by the licensed nurses and/or the Interdisciplinary Team (IDT, Interdisciplinary Team, a group of professionals to address complex problems) will be care planned and communicated to the corresponding professional and to the facility staff for implementation. The Certified Nursing Assistant (CNA). will observe and document the Resident's current voiding (urination)/bowel evacuation pattern for a minimum of three days. Following review and determination of the Resident's voiding/bowel evacuation pattern the licensed nurse will develop an individualized Bowel and Bladder Training Program to meet the Resident's needs. The established pattern and individualized bowel and bladder training interventions will be documented in the plan of care.A review of Resident 1's admission record dated 8/13/25, indicated Resident 1 was admitted to the facility from a local hospital on 8/13/25 with the diagnoses that included Urinary Tract Infections (UTI, and infection in the bladder, causing pain and increased urination), Covid-19 (infectious respiratory disease caused by a virus), difficulty in walking, muscle weakness, cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, dysphagia (difficulty with swallowing), need for assistance with personal care, chronic pain syndrome, atrial fibrillation (irregular heart beat that can cause dizziness, tiredness, lightheadedness, reduced ability to exercise, and weakness), overactive bladder (the sudden urge to urinate that may be hard to control), retention of urine (difficulty in urination), osteoarthritis (bone inflammation) of the right and left knee. A review of Resident 1's admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the seven day observation period for a MDS assessment) of 8/20/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 056074 Page 13 of 14 056074 10/27/2025 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 0=resident is severely mentally impaired to 15=resident is mentally intact.) was conducted and Resident 1 scored a 10 indicating moderate mental impairment. Section GG (functional abilities) indicated Resident 1 used a walker when walking, required moderate assistance from staff with standing, transferring to chair or bed, walking, and toilet transfers. Section H (Bowel and Bladder) indicated Resident 1 was admitted with an indwelling catheter and was continent (able to control) with her bowel movements. A review of Resident 1's Progress Notes titled Alert Note dated 8/14/25 at 11:28 am, Registered Nurse (RN) A indicated Resident 1's indwelling catheter had fallen out. A review of Resident 1's Progress Notes titled IDT Progress NotesFalls dated 8/15/25 at 7:23 am, IDT indicated Resident 1's indwelling catheter had been discontinued. A review of Resident 1's August 2025 Progress Notes indicated there was no documentation in Resident 1's progress notes to indicate why the indwelling catheter was not replaced. And there was no Alert Charting concerning Resident 1's status after the indwelling catheter was removed. A review of Resident 1's August 2025 Physician Orders indicated there was no order to discontinue the indwelling catheter. A review of Resident 1's August 2025 Assessments indicated there was no assessment of Resident 1's need for an indwelling catheter and there was no assessment for Resident 1's bladder status or bladder training after the indwelling catheter was removed. A review of Resident 1's August 2025 Care Plans indicated there was no Bowel and Bladder Base Line (a care plan that was done within three days of admission) Care Plan developed and no individualized Bowel and Bladder Training Program to meet Resident 1's bladder needs, since she would then have to use the toilet instead of a urinary catheter to empty her bladder. A concurrent interview with RN A and record review on 10/22/25 at 2:56 pm, Resident 1's 8/14/25 at 11:28 am, Progress Note titled Alert Note was reviewed. RN A said that Resident 1's indwelling catheter had fallen out and was never replaced because there was no indication (or diagnoses) to support the use of a catheter. RN A was unable to provide evidence that the physician was notified of the indwelling catheter falling out and that the Physician ordered it to have been discontinued. RN A stated that when an indwelling catheter was removed a resident was put on Alert Charting (a nursing assessment and charting every 8 hours, concerning a particular resident situation) to observe signs and symptoms of bleeding, or retention (where urine stays in the bladder and does not come out). A review of Resident 1's Alert Charting after 8/14/25 at 11:28 am, indicated there were no documented Alert Charting concerning Resident 1's bladder condition after the removal of the indwelling catheter. RN A stated that there was no bladder training done for Resident 1 because the Physician had not ordered it.During a concurrent interview with the Director of Nursing (DON) and record review on 10/22/25 at 2:56 pm, Resident 1's Progress Notes, Physician Orders, Assessments, and Care Plans were reviewed. DON reviewed Resident 1's Assessments and stated that she was not aware of an assessment to determine the need for an indwelling catheter. DON reviewed Resident 1's Physician Orders and confirmed that there was no order to discontinue Resident 1's indwelling catheter and there should have been. DON reviewed Resident 1's Assessments and confirmed that there was no bladder assessment or bladder training for Resident 1 after the indwelling catheter was left out and there should have been. DON reviewed Resident 1's care plans and confirmed that there was no Care Plan concerning Resident 1's interventions needed to restore bladder function. 056074 Page 14 of 14