Autumn Creek Post Acute: Medication Order Failures - CA
The missing medications were Clotrimazole cream and Estrace cream, both prescribed for Resident 1. Neither had been entered into the facility's electronic medical record system as an active order.
The Assistant Director of Nursing acknowledged the gap directly. During an interview the morning of the inspection, she confirmed that neither cream had been entered into Resident 1's electronic medical record and said the orders should have been there.
The Director of Nursing had already reviewed the records independently before inspectors arrived. That review reached the same conclusion: the two medications simply were not ordered for Resident 1 in the system.
The inspection classified the violation as minimal harm or potential for actual harm, affecting few residents. But a medication that exists on paper and nowhere else in the system is a medication that can be missed, skipped, or forgotten without anyone flagging it as an error. There is no order to check against. There is no prompt to administer. The gap between what was prescribed and what was documented is where harm begins.
Clotrimazole is an antifungal cream used to treat skin infections. Estrace is an estrogen cream with specific dosing requirements. Neither is a medication where informal administration, without a logged order, offers adequate protection for the patient.
The facility offered no explanation for how long the orders had been missing or whether Resident 1 had received the medications during the period they went unrecorded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Creek Post Acute from 2025-12-31 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: August 19, 2026 · Our methodology
AUTUMN CREEK POST ACUTE in CHICO, CA was cited for violations during a health inspection on December 31, 2025.
The missing medications were Clotrimazole cream and Estrace cream, both prescribed for Resident 1.
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.