Autumn Creek Post Acute: Unlocked Drug Cart - CA
No staff intervened as inspectors opened the cart's drawers at 3:15 PM on nursing station 4. Inside they discovered six one-milliliter hypodermic syringes and a 12-ounce bottle of povidone iodine with its plastic top broken off, brown residue visible on the cap.
The facility had completed a plan of correction for the identical violation just three weeks earlier.
When inspectors asked LVN A, the closest nurse to the cart, where the responsible nurse was, she said she wasn't sure. LVN A confirmed the facility's policy required all medication carts to be locked when unattended.
Administrator confirmed that LVN C, who was accountable for the treatment cart, had left early that day for a family emergency.
But LVN C told a different story the next morning. She denied the family emergency caused the unlocked cart. Instead, she said the cart was left open because the regular treatment nurse was on vacation, and leaving it unlocked was "the only way to access the medications in the cart."
She acknowledged knowing about the facility's policy requiring locked carts. She also admitted staff had left the cart unlocked previously.
Director of Staff Development B recognized the problem immediately during her interview. "She stated that she recognized that the facility was recently cited for the same med cart being unlocked in the same location," inspectors wrote.
The previous violation had triggered daily audits as part of the correction plan. She had been conducting those audits daily, she told inspectors.
"She acknowledged that some things in the cart could be a danger to residents, and if there were syringes there, that's definitely dangerous," inspectors documented. "She acknowledged that iodine in a large amount could also be dangerous around residents."
The facility's own medication storage policy, provided to inspectors, states: "Med cart locked and no unlocked meds in patient rooms."
The treatment cart was shared among nursing staff providing wound treatments, LVN C explained. But that arrangement created the access problem that led staff to leave dangerous medical supplies unsecured around vulnerable residents.
Federal inspectors had cited the facility for an open medicine cart in recent weeks. The plan of correction included daily rounds of the carts "until no incidents of carts being found open and unattended occur for 30 days." The facility marked that plan complete on July 22.
Less than a month later, inspectors found the same cart unlocked in the same location.
The violation puts residents at risk for unauthorized access to medical supplies and medications. Dementia residents, who were observed sitting in wheelchairs directly adjacent to the nursing station, face particular vulnerability due to their cognitive impairment.
Hypodermic syringes pose obvious dangers if accessed by confused residents or visitors. Povidone iodine, while used for wound care, can cause harm if ingested or misused, especially in the large quantities found in the broken bottle.
The repeated nature of the violation suggests systemic problems with medication security protocols. Despite daily audits implemented after the previous citation, staff continued unsafe practices that left controlled medical supplies accessible to residents and visitors.
The facility's explanation that vacation coverage necessitated leaving the cart unlocked reveals a fundamental misunderstanding of federal safety requirements. Medication security cannot be compromised for operational convenience, particularly in facilities serving cognitively impaired residents.
LVN C's admission that staff had previously left the cart unlocked indicates the problem extended beyond the single observed incident. The pattern of unsafe medication storage practices continued despite recent regulatory intervention and staff awareness of the policy violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Creek Post Acute from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN CREEK POST ACUTE in CHICO, CA was cited for violations during a health inspection on August 25, 2025.
No staff intervened as inspectors opened the cart's drawers at 3:15 PM on nursing station 4.
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.