Colonial Park Rehabilitation and Nursing Center was supposed to draw blood on April 14 to check vancomycin levels in Resident #1. The antibiotic can cause kidney damage if levels climb too high in a patient's system.
They didn't do it.
When the pharmacy called to follow up that day, staff said they would draw the blood on April 16. When April 16 came and went, they pushed it to April 21. Their excuse for the latest delay: the lab specimen "sat too long and needed to be redrawn."
By April 21, when staff finally tested the resident's blood, vancomycin levels were high enough to require hospitalization. The antibiotic was immediately stopped.
The delays violated basic medication monitoring protocols. Vancomycin trough levels must be drawn approximately one hour before the next scheduled dose to measure the lowest concentration in the patient's system. Resident #1 received vancomycin at 9:00 AM and 9:00 PM, meaning blood should have been drawn at 8:00 AM.
Assistant Director of Nursing #7 acknowledged during an October interview that drawing blood at 1:00 PM or 4:00 PM "would not be appropriate." The timing matters because incorrect collection can produce falsely elevated results.
"The trough was meant to see the lowest level of vancomycin in the body system, so it needed to be before the next dose," the assistant director said. "If the trough was not done at the appropriate time it could result in a higher value due to the timing of the dose completion."
But staff couldn't explain why they missed the April 14 deadline. When administrators reviewed records during the state inspection, they found no vancomycin trough results for that date. Computer records showed no laboratory results at all for April 14.
"The only vancomycin trough they could find was on 04/18/2025," according to the inspection report. Even that test appears to have been drawn incorrectly or at the wrong time.
Director of Nursing #3 said peripheral inserted central catheter blood draws were handled by registered nurses. The hospital discharge paperwork clearly outlined when vancomycin monitoring was due.
"If the resident had an order for a vancomycin draw on 04/14/2025, it should have been drawn," the director said. "They did not know why it was not done."
The resident's physician expressed alarm at the monitoring failures during a phone interview with inspectors. Physician #1 said vancomycin trough levels should be monitored daily in residents with kidney problems, or at least every three days for other patients.
"Waiting four days to draw a trough was not acceptable and they should have been notified," the doctor said.
The physician explained that elevated vancomycin levels between 40-50 micrograms per milliliter can cause kidney damage regardless of whether a patient had pre-existing kidney disease. Missing trough tests every three days "could lead to nephrotoxicity."
"If they had had the trough levels, they would have stopped the medication," the physician told inspectors.
Resident #1 was supposed to continue vancomycin treatment for approximately six weeks after hospital admission. The antibiotic requires careful monitoring precisely because therapeutic doses walk a narrow line between effectiveness and toxicity.
Registered Nurse #5 told inspectors that facility nurses drew blood from central catheters and called the lab to collect specimens. Labs typically went out Monday, Wednesday and Friday, with orders placed within a three-day window.
But the system broke down for Resident #1. Between the missed April 14 test, the unexplained April 16 delay, and the "lab sat too long" excuse for April 18, nearly a week passed before anyone measured how much vancomycin was circulating in the resident's bloodstream.
By then it was too late. The levels had climbed high enough to require emergency intervention and hospitalization.
The state cited Colonial Park for failing to ensure residents received proper treatment and services in accordance with professional standards of practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Park Rehabilitation and Nursing Center from 2025-12-01 including all violations, facility responses, and corrective action plans.