Three Creeks Post Acute
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
about insulin, the conversation had diverged a little bit and that [CC1] had asked about how many agency staff were working in the building, I countered with this is your pattern of behavior, you are angry and rude to staff, I have walked out of the room on [them] before because [they are] so rude and insulting, [they] claim [they] need assistance to use the toilet and get cleaned up after using the toilet but then the resident had walked from [their] room all the way down to the nurses station during the prior week because [they] thought [they] had been waiting too long to be changed, so [they] could walk down to the nurses station to tell the nurses that [they] had been incontinent of bowel but could not go to the bathroom by [themselves], [they] insist on sitting in [their] own feces, [they are] acrimonious, [they are] belittling. I presented that reality to [them], it was not a one sided argument, [they] lost [their] temper, told me to shut up, I was calm, I never raised my voice, [they were] not happy to have the conversation, I presented it as it seems like you are upset right now and want to stop this conversation. Staff B further stated that Yes, I probably did say that when asked if they called Resident 1 a nasty little man. Staff B then left Staff A's office. When Staff B left Staff A's office, Staff A stated that Staff B would be suspended while an investigation into the incident could occur. At 1:54 PM Staff A stated that Staff B had been suspended and had left the building. During a status update on 11/06/2025 at 3:00 PM Staff A stated that Staff B would have to be terminated. They further stated that the situation was black and white and that Staff B had admitted to verbal abuse and [they] would be terminated. Reference: (WAC) 388-97-0640(1), (5)(a), (6)(a)(b)
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Three Creeks Post Acute
Northwest 1310 Deane Pullman, WA 99163
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
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)
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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Three Creeks Post Acute in PULLMAN, WA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PULLMAN, WA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Three Creeks Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.