Autumn Creek Post Acute

F 0557

another resident in C bed get up for breakfast, I overheard another CNA [CNA A] who was helping a resident in B bed to shut f up, stop screaming you are disturbing everyone around you.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Creek Post Acute

587 Rio Lindo Avenue Chico, CA 95926

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and interview this requirement was not met when one of three sampled medication carts were left unlocked and unattended. This had the potential for unauthorized access including nearby residents with dementia, and the potential for harm. In an observation on 8/18/25 at 3:15 PM, one of three sampled treatment carts on nursing station 4 was observed to be unattended and unlocked. Drawers were opened and inspected; accessible supplies and medicines included six, 1-ml hypodermic syringes, and a 12-ounce bottle of what was labeled to be povidone iodine whose plastic top was broken off with brown residue visible on the cap. Residents were observed to be sitting in wheelchairs in the hallway directly adjacent to nursing station 4. No staff stopped or intervened as the drawer was inspected.In a concurrent interview and

observation on 8/18/25 at 3:20 PM, the closest nurse to the cart, LVN A, stated she wasn't sure where the nurse was who was responsible for the cart. LVNA confirmed that the facility's policy was for all med carts to be locked when unattended.In an interview with Administrator (ADM) on 8/18/25 at 3:30 PM, ADM confirmed that a nurse who was accountable for the treatment cart, LVN C, had left early for the day for a family emergency.In an interview on 8/19/25 at 10:00 AM, Director of Staff Development (DSD B) stated it is absolutely the facility's policy to ensure med carts are locked when not in use.DSD B stated that she recognized that the facility was recently cited for the same med cart being unlocked in the same location, and the plan of correction was daily audits, which she has been doing daily. She stated that the nurse responsible for the cart had left for a family emergency which may have contributed to the situation. She acknowledged that some things in the cart could be a danger to residents, and if there were syringes there, that's definitely dangerous. She acknowledged that iodine in a large amount could also be dangerous around residents.In an interview on 8/19/25 at 10:15 AM, LVN C stated that the treatment cart that was observed to be left open was a shared cart among the various nursing staff providing wound treatments, etc. LVN C confirmed that she had left the previous day due to a family emergency, but denied that was the reason the cart was left unlocked. LVN C stated that the cart was left unlocked because the regular treatment nurse was out on vacation, so the only way to access the medications in the cart was for staff to leave it unlocked. LVN C stated she was aware of the facility's policy for carts to remain locked when not in use. [NAME] stated that she was aware of staff having left the cart unlocked previously.In an interview and concurrent record review, Administrator (ADM) indicated that the facility had recently undergone a plan of correction for an open medicine cart. Review of the facility's Plan of Correction included Rounds of the carts daily until no incidents of carts being found open and unattended occur for 30 days. The Plan of Correction was documented as complete on 7/22/25Review of Medication Management and Storage, (undated) provided by the facility on 8/19/25 as its standard of care for medication storage, indicated, Med cart locked and no unlocked meds in patient rooms.

Event ID:

Facility ID:

If continuation sheet