The resident, identified only as Resident #1, has a tracheostomy tube, gastrostomy tube, and Foley catheter. His doctor told inspectors the tubes make him particularly vulnerable to infections because "the body looks at as a foreign object and would begin to attack."
Federal inspectors found the facility violated residents' rights to receive services included in their care plans during a November 6 complaint investigation.
The missed medication wasn't discovered until the assistant director of nursing notified the resident's doctor on November 6 that the patient "had missed several doses of his IV antibiotic therapy." The inspection report doesn't specify how many doses were missed or over what time period.
LVN F, who works the morning shift from 6 a.m. to 6 p.m., told inspectors that missing scheduled antibiotic doses "placed the resident at risk of the infection developing resistance to the antibiotic causing the resident to be given a stronger antibiotic to treat the infection." She also said it "placed other residents at risk of encountering that same bacteria."
The facility operates without a director of nursing. LVN F said she would normally inform "the doctor, Administrator and the ADON since the facility did not have a DON at present" when medication issues arose.
The resident's doctor wasn't concerned about the missed doses because the patient "was already receiving frequent scheduled doses at the hospital." But he extended the antibiotic therapy length "for precautionary measure due to resident having the following tubes (tracheostomy, gastrostomy, and Foley catheter)."
He told inspectors the infection had "more than likely resolved itself, but antibiotic therapy was extended a little longer" as a precaution.
The doctor described an ongoing cycle for this resident. "Resident #1 had a history of sepsis and going in and out of the hospital," he said. The infections would continue "due to having tubes inside of his body." Each infection would "go away until another infection occurred and had to be treated."
His prognosis is grim. "Eventually no antibiotic would help and Resident #1 would eventually pass away," the doctor told inspectors.
The facility's clinical operations appear strained. A social worker told inspectors she was handling referrals because "the NF not having a Clinical Marketer" and the chief operating officer asked if she "could assist with referrals."
When LVN F encounters a resident admitted without proper medical reports, she said she would "immediately call the hospital to get a full report on the resident." The inspection doesn't indicate whether this protocol was followed for Resident #1.
Inspectors attempted to interview the nurse practitioner by phone at 11:27 a.m. on November 6 but got no answer. They left a voicemail with a callback number. The doctor said "it was the NP that the facility would first call upon admission and then he would follow-up."
The nurse practitioner had sent the doctor a message on the morning of November 6 "informing him that Resident #1 had returned to the facility and what antibiotics he was receiving for diagnosis of pneumonia and what bacteria was being treated."
The facility's policy on resident rights, revised June 6, 2025, states that residents have "the right to receive the services and/or items included in the plan of care."
But the inspection found the facility failed to ensure Resident #1 received his prescribed IV antibiotic therapy as planned. For a resident whose doctor predicts he will eventually succumb to antibiotic-resistant infections, each missed dose represents a step closer to that inevitable outcome.
The inspection classified the violation as causing "minimal harm or potential for actual harm" affecting "some" residents. However, the consequences extend beyond one patient. As LVN F noted, antibiotic resistance doesn't stay contained to a single resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodway Nursing & Rehab from 2025-11-06 including all violations, facility responses, and corrective action plans.