Federal inspectors found that staff ignored orders for urine analysis tests and failed to send a CT scan order to the hospital for days after it was written. When confronted about the violations, nursing supervisors couldn't explain why basic medical procedures weren't completed or documented.
The most glaring failure involved Resident #75, whose CT scan order sat unprocessed for days. Agency Licensed Practical Nurse A told inspectors the order should have been sent "on the day it was ordered," but admitted being "unsure of when the CT scan had been ordered and when the order was sent to the local hospital."
The nurse described the proper procedure: call the imaging location, inform the resident about scheduling, wait for fax confirmation, and document everything in the medical record. None of this happened in a timely manner.
Director of Nursing couldn't provide any documentation proving Resident #75's CT scan order had been sent before January 27, 2026. The nursing supervisor said staff should "get confirmation that the order was received and document a progress note" but acknowledged this standard protocol wasn't followed.
Resident #44 faced similar neglect with a urine analysis order that went uncompleted. Multiple staff members knew the proper procedure but failed to execute it.
Certified Nursing Assistants A and B told inspectors that physician orders "should be followed as written" and that if they couldn't collect a urine sample, they would inform the nurse. But no such communication occurred.
The facility's own policies required staff to document progress notes when urine samples couldn't be collected. Agency LPN A explained that licensed staff needed to "document a note somewhere in the resident's EMR" when collection failed, and that nurses could document on the Treatment Administration Record whether samples had been obtained.
Yet Resident #44's medical record contained no such documentation.
The Director of Nursing expressed confusion about the systematic failures. The supervisor told inspectors that urine analysis orders would appear on the nurse Medication Administration Record, and nurses were expected to document in the MAR or progress notes if collection proved impossible.
"He/She was unsure why staff did not document a note that indicated that a UA could not be completed as ordered," the inspection report stated. "There should have been a note documented in Resident #44's EMR to indicate that a UA could not be collected."
The violations revealed a breakdown in basic nursing protocols that every staff member claimed to understand. During interviews, nursing assistants, licensed practical nurses, and the Director of Nursing all stated that physician orders "should be followed" and "should be followed as written."
LPN A told inspectors that "staff should follow all facility policies related to following physician orders and sample collection." The nurse knew exactly what should happen when orders couldn't be completed immediately but admitted the facility failed to meet these standards.
The inspection found that sometimes urine analysis orders appeared on the Treatment Administration Record, where nurses could document collection status. Other times, progress notes were the appropriate place for documentation. But in Resident #44's case, neither location contained any record of attempted collection or explanation for delays.
For CT scan orders, the process required multiple confirmation steps that staff understood but didn't implement. The nurse explained the protocol of calling the imaging center, scheduling the procedure, obtaining fax confirmation numbers, and documenting everything for the medical record.
The systematic nature of these failures suggests problems beyond isolated incidents. When basic physician orders for common diagnostic procedures aren't followed or documented, residents lose access to medical care their doctors deemed necessary.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents. But the breakdown in following physician orders represents a fundamental failure in nursing home operations that could delay critical medical interventions for vulnerable residents who depend entirely on staff to coordinate their healthcare.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Years Center For Rehab and Healthcare from 2026-01-30 including all violations, facility responses, and corrective action plans.