Three Creeks Post Acute

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 2 of 3 sampled residents (Resident's 2 and 3) reviewed for medication management.

This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted.

Findings included . <Resident 2>The 09/11/2025 admission assessment documented Resident 2 had diagnoses which included osteomyelitis (a bone infection that spreads through the bloodstream) and sepsis (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).

The resident was cognitively intact and able to make their needs known.The 09/06/2025 wound infection care plan documented Resident 2 would be free of an acute infection.

Nursing staff were instructed to give medications as ordered.A 09/05/2025 hospital discharge order documented Resident 2 was supposed to have Vancomycin (an antibiotic used to treat infections) for six weeks and the treatment was to end on 10/13/2025.A review of the October 2025 Medication Administration Record (MAR) documented the following order: -Vancomycin 1000 grams, give 1 gram every 12 hours for osteomyelitis until 10/03/2025.

The medication was discontinued after the 10/03/2025 doses were administered.On 11/10/2025 at 12:22 PM, the pharmacy the facility used was contacted. A pharmacist stated the original order for the Vancomycin was through 10/13/2025 and they had received an updated order on 09/14/2025 to give the Vancomycin until 10/03/2025.In an interview on 11/10/2025 at 1:03 PM, Staff D, Resident Care Manager, stated the original stop date for the Vancomycin was 10/13/2025.

Staff D said the last order received to change the dose of the medication was on 09/14/2025 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.In an interview on 11/10/2025 at 2:18 PM, Staff F, Medical Director, stated she spoke to the physician who gave the order, and they made an error when they had typed the order.

Staff F stated the Vancomycin should have been given through 10/13/2025.<Resident 3>The 11/03/2025 care plan documented Resident 3 had diagnoses including diabetes, high blood pressure and an amputation.

The resident was cognitively intact and able to make their needs known.A review of the November 2025 MAR documented the following orders:-Doxycycline (antibiotic) 100 milligrams was ordered twice daily on 11/02/2025 for an infection times seven days.

The medication was to be discontinued after the 11/05/2025 doses.-Doxycycline 100 milligrams was ordered twice daily on 11/05/2025 to continue indefinitely.

The MAR was blank on the evening of 11/05/2025.In an interview on 11/10/2025 at 2:43 PM, Staff D stated Resident 3 should have received their Doxycycline and it was a medication error that they did not.

Staff D stated it was important for the residents to receive their full doses of antibiotics, so they were effective.In an interview on 11/10/2025 at 2:50 PM, Staff E, Licensed Practical Nurse, stated they gave Resident 3 their antibiotic. Resident 3 stated after they administered medication to a resident, they would click that it was given in the MAR.

Staff E pulled up the administration record for the Doxycycline on 11/05/2025 and it was red.

Staff E stated that if it was red on the MAR it meant the medication was late and if it stayed red it was not administered.Reference: WAC 388-97-1060(3)(k)(iii)

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