Creasy Springs Health Campus: Medication Mix-Up - IN
The inspection, completed September 30, 2025, documented what happened to Resident B after he was admitted to Creasy Springs Health Campus. A licensed practical nurse, identified in the report as LPN 3, transcribed his medications correctly from the hospital. The next step was for a registered nurse, RN 2, to review those transcriptions. RN 2 did not do that.
Instead, RN 2 admitted a second patient, Resident C, and entered that person's medications into Resident B's chart by mistake. Nobody ran the required second check.
The result: Resident B had 11 incorrect medication entries in his record. Over the next four days, August 15 through August 18, he received 23 doses of medications he was never supposed to have.
The list of drugs he received in error was long. It included metoprolol, used to treat heart conditions. Pantoprazole, for stomach acid. Aspirin. Atorvastatin, a cholesterol medication. Amlodipine, for blood pressure. Potassium chloride, an electrolyte supplement, given three times in error on August 16, 17, and 18. Tramadol, a pain medication. Trazodone, an antidepressant, given three times in error on August 15, 16, and 17. Meclizine, for nausea and dizziness. And senna, a laxative.
The error was not caught by staff during those four days. It was Resident B's wife who noticed something was wrong.
She reviewed some of her husband's listed medications with LPN 3. That conversation prompted a call to the nurse practitioner, and some of the incorrect medications were discontinued on August 16. But the review that followed was not complete. Neither the nurse practitioner nor LPN 3 finished a full check of Resident B's medication list at that point.
The second full check didn't happen until August 18. That's when the scope of the error became clear.
The facility's Director of Health Services confirmed the sequence of events during an interview on September 29. The director told inspectors that LPN 3 had transcribed the correct medications from the hospital, that RN 2 was responsible for reviewing those transcriptions, and that RN 2 had not done so. The records for both Resident B and Resident C were not double-checked as required.
RN 2, interviewed the following day, did not dispute any of it. She told inspectors she had not completed the second check for Resident B's admission orders. She confirmed she had admitted Resident C and entered his orders. She acknowledged that all new admission orders were supposed to be verified by a second nurse.
Resident C had no medication errors.
After the full review on August 18, the physician went through Resident B's medications and updated the orders. The facility monitored Resident B for adverse reactions, according to the report. The inspection narrative does not document that he suffered lasting harm from the 23 incorrect doses.
The facility's own written policy, which the Director of Health Services provided to inspectors on September 30, described the five rights of medication administration: right resident, right drug, right dose, right route, right time. The same policy stated that if a medication order seemed unrelated to a resident's diagnosis or conditions, staff should contact the pharmacy or prescriber before giving it.
Another policy required that medication orders be recapped and that a second nurse review admission orders.
On August 15, 16, 17, and 18, none of that happened for Resident B.
What did happen was that a man arrived at a nursing facility after a hospital stay, and for four days received more than two dozen doses of medications prescribed for someone else, in some cases multiple times a day. The error was classified as causing minimal harm or potential for actual harm. It affected a small number of residents.
The full picture of what those four days meant for Resident B is not in the inspection report. What is there is the record of his wife, reviewing a medication list that didn't look right, and asking a nurse to explain it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creasy Springs Health Campus from 2025-09-30 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 26, 2026 · Our methodology
CREASY SPRINGS HEALTH CAMPUS in LAFAYETTE, IN was cited for violations during a health inspection on September 30, 2025.
The inspection, completed September 30, 2025, documented what happened to Resident B after he was admitted to Creasy Springs Health Campus.
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.