Autumn Creek Post Acute

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Creek Post Acute

587 Rio Lindo Avenue Chico, CA 95926

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Creek Post Acute

587 Rio Lindo Avenue Chico, CA 95926

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: