Health inspection·January 6, 2026

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review, the facility failed to ensure Nurse's Aides (NA, in training) were state certified prior to hiring and had competencies to provide direct resident care independently.This had the potential for all residents to not have their care needs met and at risk for injury when nine uncertified Nurse's Aides provided unsupervised direct resident care. Refer to F839.Findings:A review of Facility 1's records indicated they did not have an approved Nursing Assistant Training Program (NATP, six-week NA training program) that required approval from the California Department of Public Health (CDPH). A review of Facility 1's Current CNA/NA employee list indicated there are currently nine uncertified Nursing Assistants (NAs) identified as INS-Staff Training Aides on the list.A review of Facility 1's Nursing Assistant Job Description, undated, indicated, The Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the nursing care activities in which the nursing assistant has received clinical instruction and demonstrated competency. Under the Qualifications section, it stated, NA's must be currently enrolled in a NATP, that required approval from CDPH. NAs must have clinical competency while enrolled in the NATP.A review of Facility 1's NA's Can and Can't Do List undated, indicated NAs cannot provide direct resident observation, take vital signs, change briefs, feed residents, transfer residents, or any direct resident care at all.During an interview on 12/5/25 at 11:40 am, the Director of Staff Development (DSD), who worked at Facility 1, explained only Facility 2 had state approval for the NATP classes. DSD stated Facility 1, 2 and 3 meet before each NATP session and interview potential NA students and then hire five at each facility. DSD stated once NATP class were completed the five NAs are oriented to Facility 1 for 2 days then paired and shadowed another CNA for training and competencies. A review of Facility 1's nursing staff assignment sheets dated 11/3-11/7/2025 and 12/3-12/10/2025, indicated uncertified NAs were assigned to take vital signs and take resident assignments. NAs were taking vital signs and working independently and were not paired with a specific CNA for supervision.A review of CNA/NA list and the California Certified Nurse's Assistant Registry (certification verification website) on 1/13/2026 at 11:48 am, indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/6/2025. On 11/3/2025-11/5/2025, NA 1 was assigned to train with CNA 1 on the morning (AM) shift (6:30 am to 2:30 pm).NA 2 was hired on 9/5/2025, graduated on 10/17/2025, and remains uncertified to date (1/13/2026).On 11/5/2025 NA 2 was assigned a resident assignment with CNA 2 on PM (afternoon) shift (2:30 pm to 10:30 pm). On11/7/2025, NA 2 was assigned a resident assignment to train with CNA 3 on PM shift. On12/5/2025, NA 2 was assigned a resident assignment with CNA 10 on PM shift. From 12/6/2025-12/7/2025, NA 2 was assigned to vital signs and a resident assignment with CNA 2 on PM shift.NA 3 was hired on 10/22/2025 and became a certified Nurse's Aide on 12/19/2025. On 11/3/2025-11/4/2025, NA 3 was assigned to a resident assignment train with CNA 4 on night shift (NOC, 10:30 pm to 6:30 am). On 11/7/2025, NA 3 was assigned independently to a resident Page 1 of 5 056074 056074 01/06/2026 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assignment on NOC shift. From 12/3/2025-12/4/2025, NA3 assigned a resident assignment with CNA 8 on NOC shift. From 12/6/2025-12/8/2025, NA 3 was assigned to vital signs on NOC shift, not paired with CNA.NA 4 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/6/2025. On11/3/2025, NA 4 was assigned a resident assignment with CNA 5 on the NOC shift. On 11/4/2025, NA 4 was assigned a resident assignment with CNA 6 on NOC shift. On 12/3/2025, NA 4 was assigned a resident assignment with CNA 9. On 12/4/2025, NA 4 was assigned a resident assignment with CNA 5. On12/6/2025, NA 4 was assigned to a resident assignment with CNA 6 on NOC shift.NA 5 was hired on 6/23/2025 and became a CNA on 1/12/2026. From 11/3/2025-11/7/2025, NA 5 were assigned to take vital signs independently on PM shift, not paired with a CNA. On12/4/2025,12/5/2025, and 12/8/2025, NA 5 was assigned to vital signs on PM shift, not paired with CNA.NA 6 was hired in June 2025, graduated 8/8/2025, and became a CNA on 1/7/2026. From 11/3/2025-11/7/2025, NA 6 was assigned to take vital signs independently on PM shift, not paired with a CNA. On 12/3/2025, 12/5/2025, and 12/8/2025, NA 6 was assigned to take vital signs on residents during the AM shift, not paired with CNA.NA 7 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/16/2025. On12/3/2025-12/5/2025, NA 7 was assigned a resident assignment with CNA 7 on NOC shift.NA 9 was hired on 6/13/2025 and became a CNA on 9/20/2025. On11/3/2025,11/4/2025,11/6/2025, and 11/7/2025, NA 9 was assigned to take vital signs independently on AM shift, not paired with CNA.During an interview with CNA 11 on 12/5/2026 at 12:15 pm, CNA 11 stated, they worked with a student NA last Friday on Station 2 that came from the NATP for Facility 1. They stated most NAs get hired after skills and written test were completed and were assigned to a unit working independently not paired with a CNA.During an interview with CNA 12 on 12/5/2025 at 12:21 pm, CNA 12 stated they had worked at Facility 1 since June 2025 and were assigned NAs to shadow (follow and observe) them. CNA 12 stated NAs were coming from Facility 1 and Facility 2's NATP and were usually hired after they were certified. CNA 12 stated there were a lot of new staff.During an interview with Administrator (Admin) for Facility 1 on 12/5/2025 at 12:45 pm, Admin stated uncertified NAs had been working at Facility 1 on the PM and NOC shifts. Admin stated they were not aware that uncertified NA and NA students were not allowed to be employed or have clinical training at Facility 1. Admin stated, the NATP and clinical routines were established under the previous leadership of Facility 1. Admin stated they plan to bring uncertified NAs back to AM shift for better supervision. Admin stated that currently uncertified NAs were supervised by the DSD.During an interview with NA 8 on 12/8/2025 at 9:02 am during their shift, NA 8 stated they were currently waiting to complete certification testing and they started working for Facility 1 on 6/1/2025. NA 8 stated they were not allowed to perform hands on care with residents but they had a couple of times because a resident was in need and no one was available.A review of CNA/NA staffing lists indicated NA 8 was hired on 4/14/2025.A review of the California CNA registry indicated, NA 8 remains uncertified to date (1/13/2026).During an interview on 12/10/2025 at 1:25 pm with NA 5, NA 5 stated they had worked at Facility 1 since August 2025 as an NA on the PM shift. They stated they were waiting for their state certification identification number. NA 5 stated they provided direct observation for fall risk residents, had independent assignments, and were occasionally paired with a CNA to shadow the CNA if the CNA wanted to show me how to perform a care task.During an interview with NA 2 on 12/10/2025 at 1:40 pm, NA 2 stated they were currently waiting for their state certification identification number. NA 2 stated they had been shadowing (direct resident care with the supervision of a CNA). NA 2 stated they worked with another NA who was also waiting for their state certification numbers.During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they 056074 Page 2 of 5 056074 01/06/2026 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 056074 Page 3 of 5 056074 01/06/2026 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interview and record review the Governing Body failed to provide oversight to a facility's Administration to ensure nine nurse's aides were state certified and had the competencies required prior to providing care to residents independently.This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.Findings:A review of Facility 1's Operations Manual Administrative Policies dated 6/4/2024, indicated the Governing Body (GB) engages Administrative Services to develop policies and procedures for the management and operations of the facility. The GB will review and confirm the adoption of all new and updated policies and procedures regarding the management and operations of the facility at least on an annual basis. The GB will direct the facility administrator to report any deviations from the template policies to the committee responsible for managing the policies and procedures. A review of Facility 1's current CNA/NA employee list undated, indicated there were nine uncertified Nursing Assistants.A review of Facility 1's Nursing Assistant Job Description, undated, indicated, The Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the nursing care activities in which the nursing assistant has received clinical instruction and demonstrated competency. Under the Qualifications section, it stated, NA's must be currently enrolled in a Nursing Assistant Training Program (NATP, six-week NA training program) that required approval from the California Department of Public Health (CDPH). NAs must have clinical competency while enrolled in the NATP.A review of Facility 1's NA's Can and Can't Do List undated, indicated NAs cannot provide direct resident observation, take vital signs, change briefs, feed residents, transfer residents, or any direct resident care at all. During an interview on 12/5/25 at 11:40 am, the Director of Staff Development (DSD), who worked at Facility 1, explained only Facility 2 had state approval for the NATP classes. DSD stated Facility 1, 2 and 3 meet before each NATP session and interview potential NA students and then hire five at each facility. DSD stated once NATP class were completed the five NAs are oriented to Facility 1 for 2 days then paired and shadowed another CNA for training and competencies. A review of Facility 1's nursing staff assignment sheets dated 11/3-11/7/2025 and 12/3-12/10/2025 on 12/30/2025 at 7:30 am, indicated uncertified NAs are assigned to take vital signs and take resident assignments. NAs were taking vital signs and working independently and were not paired with a specific CNA for supervision. A review of CNA/NA list and the California Certified Nurse's Assistant Registry (certification verification website) on 1/13/2026 at 11:48 am, indicated:NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 12/6/2025.On 11/3/2025-11/5/2025 NA 1 was assigned to train with CNA 1 on AM shift (6:30 am to 2:30 pm).NA 2 was hired on 9/5/2025, graduated on 10/17/2025, and remains uncertified to date (1/13/2026).On 11/5/2025 NA 2 was assigned a resident assignment with CNA 2 on PM shift (2:30 pm to 10:30 pm).On11/7/2025 NA 2 was assigned a resident assignment to train with CNA 3 on PM shift.On12/5/2025 NA 2 was assigned a resident assignment with CNA 10 on PM shift. From 12/6/2025-12/7/2025 NA 2 was assigned to vital signs and a resident assignment with CNA 2 on PM shift.NA 3 was hired on 10/22/2025 and became a certified Nurse's Aide on 12/19/2025. On 11/3/2025-11/4/2025 NA 3 was assigned to a resident assignment train with CNA 4 on night shift (NOC, 10:30 pm to 6:30 am).On 11/7/2025 NA 3 was assigned independently to a resident assignment on NOC shift. From 12/3/2025-12/4/2025 NA3 assigned a resident assignment with CNA 8 on NOC shift. From 12/6/2025-12/8/2025 NA 3 was assigned to vital signs on NOC shift, not paired 056074 Page 4 of 5 056074 01/06/2026 Autumn Creek Post Acute 587 Rio Lindo Avenue Chico, CA 95926

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with CNA.NA 4 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/6/2025. On11/3/2025 NA 4 was assigned a resident assignment with CNA 5 on the NOC shift. On 11/4/2025 NA 4 was assigned a resident assignment with CNA 6 on NOC shift. On 12/3/2025 NA 4 was assigned a resident assignment with CNA 9.On 12/4/2025 NA 4 was assigned a resident assignment with CNA 5.On12/6/2025 NA 4 was assigned to a resident assignment with CNA 6 CNA on NOC shift.NA 5 was hired on 6/23/2025 and became a CNA on 1/12/2026. From 11/3/2025-11/7/2025 NA 5 were assigned to take vital signs independently on PM shift, not paired with a CNA. On12/4/2025,12/5/2025, and 12/8/2025 NA 5 was assigned to vital signs on PM shift, not paired with CNA.NA 6 was hired in June 2025, graduated 8/8/2025, and became a CNA on 1/7/2026. From 11/3/2025-11/7/2025 NA 6 were assigned to take vital signs independently on PM shift, not paired with a CNA. On 12/3/2025, 12/5/2025, and 12/8/2025 NA 6 was assigned to take vital signs on residents during the AM shift, not paired with CNA.NA 7 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became a CNA on 12/16/2025. On12/3/2025-12/5/2025 NA 7 was assigned a resident assignment with CNA 7 on NOC shift.NA 9 hired on 6/13/2025 and became a CNA on 9/20/2025. On11/3/2025,11/4/2025,11/6/2025, and 11/7/2025 NA 9 was assigned to take vital signs independently on AM shift, not paired with CNA.A review of CNA/NA staffing lists indicated NA 8 was hired on 4/14/2025.A review of the California CNA registry indicated, NA 8 remains uncertified to date (1/13/2026).During an interview with Administrator (Admin) for Facility 1 on 12/5/2025 at 12:45 pm, Admin stated uncertified NAs are and have been working at Facility 1 on the PM and NOC shifts. Admin stated they were not aware that uncertified NA and NA students were not allowed to be employed or have clinical training at Facility 1. Admin stated, the NATP and clinical routines were established under the previous leadership of Facility 1. Admin stated they plan to bring uncertified NAs back to AM shift for better supervision. Admin stated that currently uncertified NAs are supervised by the DSD. During an interview on 12/10/2025 at 1:25 pm with NA 5, NA 5 stated they have worked at Facility 1 since August 2025 as an NA on the PM shift. They stated they are waiting for their state certification identification number. NA 5 stated they provide direct observation for fall risk residents, have independent assignments, and are occasionally paired with a CNA to shadow the CNA if the CNA wants to show me how to perform a care task. During an interview with NA 2 on 12/10/2025 at 1:40 pm, NA 2 stated they are currently waiting for their state certification identification number. NA 2 stated they have been shadowing (direct resident care with the supervision of a CNA). NA 2 stated they work with another NA who was also waiting for their state certification number.During an interview with the Governing Body, with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations. 056074 Page 5 of 5