Three Creeks Post Acute discontinued vancomycin for Resident 2 on October 3, even though hospital discharge orders specified the antibiotic should continue until October 13 to treat osteomyelitis and sepsis.
The resident had arrived at the facility in September with diagnoses that included osteomyelitis, a bone infection that spreads through the bloodstream, and sepsis, described in the inspection report as "a life-threatening medical emergency that happens when your body's response to an infection triggers a chain reaction throughout your body, causing widespread inflammation and damage to organs."
Hospital discharge orders from September 5 documented that Resident 2 was supposed to receive vancomycin for six weeks, with treatment ending on October 13.
But the facility's medication records showed something different. The October medication administration record listed vancomycin "until 10/03/2025" instead of the prescribed end date of October 13. Staff administered the final doses on October 3 and stopped.
When inspectors contacted the pharmacy on November 10, a pharmacist confirmed the original order ran through October 13. The pharmacy had received an updated order on September 14 changing the end date to October 3, but this contradicted the hospital's six-week treatment plan.
Staff D, the facility's Resident Care Manager, told inspectors the original stop date was October 13. Staff D said the last order to change the medication dose came on September 14, and "they thought the Director of Nursing meant to put the stop date for 10/13/2025 on the order but instead put 10/03/2025."
The Medical Director, Staff F, confirmed the error after speaking with the prescribing physician. "Staff F stated the Vancomycin should have been given through 10/13/2025," according to the inspection report.
A second resident faced different medication problems. Resident 3, who had diabetes, high blood pressure and an amputation, was prescribed doxycycline to treat an infection.
The November medication records showed two overlapping orders for the same antibiotic. The first doxycycline order, written November 2, was supposed to run for seven days and end after November 5 doses. A second order, written November 5, directed staff to continue the antibiotic indefinitely.
But the medication administration record was blank for the evening dose on November 5.
Staff D acknowledged the missed dose when questioned by inspectors. "Staff D stated Resident 3 should have received their Doxycycline and it was a medication error that they did not." The care manager emphasized that "it was important for the residents to receive their full doses of antibiotics, so they were effective."
The licensed practical nurse who was supposed to give the medication, Staff E, initially claimed to have administered it. Staff E told inspectors they gave Resident 3 the antibiotic and would have clicked in the medication record to show it was given.
When Staff E pulled up the administration record during the interview, the entry for November 5 doxycycline appeared in red. Staff E explained that red meant "the medication was late and if it stayed red it was not administered."
Both residents were cognitively intact and able to communicate their needs, according to their care plans.
The facility's own infection care plan for Resident 2 stated the resident "would be free of an acute infection" and instructed nursing staff to "give medications as ordered." The plan directly contradicted the early discontinuation of the prescribed antibiotic treatment.
Federal inspectors found the medication errors placed residents at risk of worsening chronic health conditions and "unintended consequences when doses of their medications were omitted."
The vancomycin error was particularly significant because the antibiotic treats serious bone infections that can be life-threatening if undertreated. Stopping the medication 10 days before the prescribed completion date could allow the infection to return or become resistant to treatment.
The doxycycline omission represented a different type of failure - staff believing they had given medication that records showed was never administered, suggesting problems with both medication delivery and documentation systems.
Both cases involved antibiotics, medications where missed or shortened doses can reduce effectiveness and contribute to antibiotic resistance.
The inspection, conducted November 10 in response to a complaint, found the facility failed to ensure residents received medications as ordered. State regulators classified the violations as causing minimal harm or potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Creeks Post Acute from 2025-11-10 including all violations, facility responses, and corrective action plans.