The facility's Director of Nursing admitted she had never collected urine samples from three residents before continuing their antibiotic prescriptions, and failed to reassess whether any of the four residents actually needed the medications.
R6 started taking Macrobid on January 2 despite not having an acute urinary tract infection at the time. The physician's order showed no stop date for the antibiotic. Director of Nursing V2 told inspectors on January 28 that R6 was prescribed the medication "because R6 has a history of having so many UTIs."
No repeat urinalysis was completed before R6 started the antibiotic. V2 admitted she had not reassessed R6 for continued need of the medication in the 26 days since it began.
R13 received Cephalexin every morning starting December 30, with the physician order listing only "prophylaxis" as the reason. No associated diagnosis appeared on the order, and no stop date was included.
V2 told inspectors the hospice service prescribed Cephalexin "because of R13's history of UTI's, not because R13 had an acute UTI at the time." The facility had never collected a urinalysis from R13 to assess his urine before starting the antibiotic.
She had never spoken with R13's hospice service about his continued need for the medication.
R14 took Bactrim twice weekly starting November 11 for "prophylaxis related to personal history of urinary tract infections." The order specified no stop date.
V2 said R14 takes the antibiotic "because R14 apparently has had bad UTIs in the past and she wants to be on it." R14 had never been diagnosed with an acute UTI while living at the facility. Staff had never collected a urinalysis from R14 during her entire stay.
V2 admitted she had never discussed R14's continued Bactrim usage with the facility's nurse practitioner.
The fourth resident, R15, received Nitrofurantoin daily from December 21 through January 9 for "UTI prevention." R15 had been admitted from a local hospital with the antibiotic order already in place.
"We just carried the order over from the hospital for his Nitrofurantoin because he had a history of UTI's," V2 told inspectors. "We never checked a urinalysis on R15 prior to continuing the medication. I never spoke with the nurse practitioner about the need to continue this medication."
V2 described herself as responsible for antibiotic surveillance at the facility, sharing infection prevention duties with the administrator who was not a nurse. She said she reviews residents' antibiotic orders monthly and examines prophylactic antibiotic orders with the facility's nurse practitioner to ensure medical necessity.
Yet her own admissions revealed systematic failures in this process.
V2 acknowledged that some residents stayed on antibiotics prophylactically "because they were admitted with the order or the resident or family just wants them to stay on the antibiotic." She said all antibiotic orders should include an associated diagnosis and stop date.
The facility's own Antibiotic Stewardship policy from December 2022 requires all antibiotic orders to include drug name, dose, frequency, start date, stop date, route of administration, and indications for use. The policy states antibiotics will be prescribed and administered under guidance of the facility's stewardship program.
Federal inspectors reviewed 17 residents for unnecessary medications and found violations affecting four of five residents examined for antibiotic misuse.
The inspection occurred following a complaint. Federal regulators classified the violations as causing minimal harm or potential for actual harm to residents.
Unnecessary antibiotic use contributes to the development of drug-resistant bacteria and can cause side effects including digestive problems, allergic reactions, and increased risk of other infections. Prolonged antibiotic use without medical justification violates federal nursing home regulations requiring each resident's drug regimen to be free from unnecessary medications.
The facility's systematic failure to test urine before prescribing or continuing antibiotics, combined with the Director of Nursing's admission that she never reassessed residents' continued need for the medications, represents a breakdown in basic pharmaceutical oversight.
V2's acknowledgment that some residents remained on antibiotics simply because families wanted them to continue, or because orders were carried over from hospitals without review, suggests the facility prioritized convenience over medical necessity.
None of the four residents had documented acute infections justifying their antibiotic use during the periods examined by inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Resthave Home-whiteside County from 2026-01-29 including all violations, facility responses, and corrective action plans.