Resident 2 arrived at Arcadia Care Center on January 7, 2025, with a urinary tract infection caused by carbapenem-resistant Enterobacterales, a group of bacteria resistant to most antibiotics. The hospital had discharged the patient specifically to continue intravenous Avycaz treatment through January 13.
The next day, MD 1 canceled the antibiotic order.
"MD 1 discontinued Resident 2's Avycaz due to the cost," the facility's outside pharmacy told inspectors. The medication required prior authorization from insurance, which the doctor had not obtained.
The resident received no alternative treatment. No antibiotics at all.
MD 1 ordered a urine culture on January 8 to find a cheaper alternative, but nursing staff never collected the sample. The test sat unperformed for four days while the infection festered.
"Resident 2 did not receive any antibiotics or other treatment at SNF 1 for Resident 2's UTI from 1/8/2025 through 1/12/2025," MD 1 told inspectors during a January 29 phone interview.
By January 12, the resident had developed confusion. The next day, altered mental status and abnormal lab results triggered an ambulance call to the same hospital that had discharged the patient six days earlier.
"Resident 2 was brought in by emergency medical services due to increased confusion and abnormal laboratory test results," hospital records show. "Because of the high cost of the antibiotics (ceftazidime-avibactam), SNF 1 had not given the antibiotics to Resident 2 since Resident 2 was discharged from GACH 1."
The emergency department note was blunt: the nursing home had simply refused to provide the prescribed medication due to expense.
Resident 2's family member, identified as RP 2, told inspectors the patient "was in pain, confused and was not communicated with regarding treatment." The relative said MD 1 claimed "no facility would have covered" the nearly $1,000-per-vial medication.
"I did not understand how the facility accepted Resident 2 as a resident when the facility was not going to carry out GACH 1's instructions," RP 2 said.
The resident described the experience as feeling "really lousy and pushed aside." When asked about having to return to the hospital instead of going home as planned, the patient told inspectors: "I wanted everything to end. I wished it was over, and I had a pistol to end it right there."
The admitting nurse, RN 1, expected the pharmacy to deliver Avycaz on January 8 but learned that day the doctor had discontinued it. RN 1 told inspectors that accepting a discontinuation order based on cost would be unacceptable.
"If RN 1 carried out a discontinuation order for antibiotics because it was too expensive, the resident could get sicker and require rehospitalization, which could affect their health in a negative way," the nurse said. "A resident's infection could get worse and cause complications that make them sicker."
That's exactly what happened.
MD 1 acknowledged the consequences during the inspection interview. "It was important for Resident 2 to get the antibiotics needed and to finish the ordered course of antibiotics to treat bacterial infection, otherwise the infection could get worse, and Resident 2 could end up in the hospital and the infection could lead to death."
The doctor also admitted that failing to collect the ordered urine sample "caused a delay in Resident 2's care which resulted in Resident 2's rehospitalization."
The facility's Director of Nursing was equally direct about the preventable harm. "Resident 2's unresolved UTI, AMS, and rehospitalization could have been avoided had Resident 2 been given Avycaz as instructed by GACH 1."
But the DON also revealed a troubling institutional failure. When MD 1 discontinued the antibiotic without ordering alternative treatment, "the DON did not question why MD 1 discontinued the Avycaz even though no alternative treatment was ordered."
The pharmacy confirmed the medication was available but expensive. Pharm 1 from the outside pharmacy said staff called MD 1 to discuss the Avycaz order after receiving it on January 7. At 4:28 a.m. on January 8, the doctor discontinued it due to cost.
Avycaz typically requires prior authorization because of its price, but MD 1 had not sought insurance approval, leaving the facility responsible for the full cost.
The resident ultimately received a four-day extension of the antibiotic course that should have been completed January 13. Instead of going home as planned, the patient endured additional days in the nursing home to finish treatment that had been interrupted by a cost calculation.
The facility's own policies required continuing hospital discharge orders for antibiotic therapy. The Antibiotic Stewardship policy stated that when residents are admitted from acute care facilities, "the admitting nurse will review the discharge and transfer paperwork for current antibiotic/anti-infective orders."
The UTI protocol required physicians to "order appropriate treatment for verified or suspected UTIs" and to "review the status of individuals who are being treated for a UTI and adjust treatment accordingly."
Neither happened. The resident went five days without any treatment for a life-threatening infection while a urine culture that could have identified alternatives sat uncollected in the doctor's orders.
The case illustrates how financial considerations can override medical necessity in nursing homes, even when dealing with deadly antibiotic-resistant infections. The resident's daughter had to advocate for treatment while her parent suffered confusion and pain from an untreated infection that required immediate intervention.
Federal inspectors found the facility failed to provide necessary laboratory services and ensure appropriate medical treatment, violations that directly contributed to the resident's deteriorating condition and emergency hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Center from 2025-01-30 including all violations, facility responses, and corrective action plans.