Autumn Creek Post Acute: Family Not Notified of Care Change - CA
Inspectors visiting Autumn Creek Post Acute on October 27, 2025, found that the facility had failed to notify the family of Resident 1 after her indwelling urinary catheter fell out and a physician decided not to replace it. The daughter, identified in inspection records as Daughter A, had her request documented in a Social Service progress note dated August 15, 2025. The note was clear: she wanted to be informed of any changes.
She wasn't.
A registered nurse identified as RN A confirmed to inspectors that no documentation existed showing the family or the resident's responsible party had been notified about the catheter decision. The physician had made the call not to reinsert the catheter after it fell out. That was a change in the resident's care. And the person who had specifically asked to know about such changes was left uninformed.
The Director of Nursing reviewed the August progress note alongside inspectors during an interview on October 2, 2025, at 3:55 in the afternoon. She confirmed that Daughter A had indeed requested notification of any changes in her mother's condition. When asked why the daughter hadn't been contacted, the Director of Nursing said she wasn't sure.
That answer, offered by the facility's top nursing official, captures the problem precisely. The request was documented. The change happened. The notification didn't.
Removing an indwelling urinary catheter, or deciding not to replace one that has fallen out, is not a minor administrative detail. A catheter manages how a person's body handles one of its most basic functions. A family member who has asked to be kept informed about their loved one's condition has a reasonable expectation that a decision of that nature would prompt a phone call. At Autumn Creek Post Acute, it didn't.
The inspection cited this as an F0580 deficiency, a tag covering the requirement that facilities notify residents and their representatives of changes in condition. Inspectors assessed the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected.
The facility is located at 587 Rio Lindo Avenue in Chico.
What the inspection record leaves unresolved is simpler and harder than any regulatory tag. Daughter A had done what families are told to do. She had made her wishes known, in a documented note, through the facility's own social services staff. She had said, in effect: keep me in the loop. And when something changed, the loop closed without her.
The Director of Nursing didn't have an explanation. The nurse confirmed there was no paperwork showing anyone had tried. Somewhere between the physician's decision and the daughter's phone, the notification stopped.
It didn't happen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Creek Post Acute from 2025-10-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
AUTUMN CREEK POST ACUTE in CHICO, CA was cited for violations during a health inspection on October 27, 2025.
The daughter, identified in inspection records as Daughter A, had her request documented in a Social Service progress note dated August 15, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.