Autumn Creek Post Acute
Inspection Findings
F-Tag F0609
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 report an abuse allegation for Resident 1 within the required timeframe when a Certified Nursing Assistant (CNA 1) was witnessed shoving him back forcefully into his wheelchair.This failure had the potential to put all residents at continued risk for abuse by staff.
Findings
A review of the facility policy titled AN01 Abuse Prevention and Management with the effective date of 06/12/2024 Indicated Purpose: To address the health, safety, welfare, dignity, and respect of residents. Reports of resident abuse, mistreatment, neglect exploitation, injuries of an unknown sources, and any suspicion of crimes are promptly reported and thoroughly investigated. P-AN01 with the effective date of 06/12/2024 indicated 7 Notification of Outside Agencies for all Allegations of Abuse. a. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written report to
the Ombudsman, Law Enforcement, and California Department of Public Health (CDPH), and Certification within (2) hours.A review of Resident 1's record indicated he was admitted to the facility on [DATE REDACTED], with diagnoses which included stroke with left side weakness and needed assistance with care. Resident 1 was able to make his own health care decisions. A review of facility incident report received by the California Department of Public Health (CDPH) dated 12/24/25 at 5:10 pm, indicated CNA 3 documented and reported to Licensed Nurse (LN 4) on 12/23/25 at 6:50 pm, an allegation of abuse. CNA 3 observed CNA 1 forcefully grab Resident 1's shirt and shoulders and shoved him back in his wheelchair to prevent a fall, then CNA 2 stated to Resident 1 see this is why we don't get you up. Administrator (Admin) of the facility reported this incident late on 12/24/25 at 5:10 pm, to CDPH.During a concurrent interview and record
review on 12/29/2025 at 11:01 am, Admin stated the timeframe for reporting allegations of abuse was within 24 hours if there are no injuries. After reviewing the facility's abuse policy, Admin confirmed the reporting time was immediately or within 2 hours after an abuse allegation is made. Admin confirmed the facility had not reported the allegation of abuse to Resident 1 in accordance with their Abuse Policy.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AUTUMN CREEK POST ACUTE in CHICO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHICO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN CREEK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.