The facility's Director of Nursing admitted she had never collected urine samples from three of the residents before starting or continuing their antibiotic treatments. In one case, a resident received the antibiotic Macrobid for nearly a month despite having no active urinary tract infection.
Resident 6 started taking Macrobid on January 2nd based on a physician's order that listed no stop date for the medication. The nursing director, identified as V2, told inspectors the resident "was started on Macrobid despite not having an acute UTI at the time, but because R6 has a history of having so many UTIs."
No repeat urinalysis was completed before starting the antibiotic. V2 admitted she had not reassessed the resident's continued need for the medication in the 26 days since treatment began.
Resident 13 presented a similar pattern. The resident began taking Cephalexin on December 30th after his hospice service prescribed the antibiotic "because of R13's history of UTI's, not because R13 had an acute UTI at the time." The facility never collected a urine sample to assess the resident's condition before starting the medication.
V2 told inspectors she had never spoken with the hospice service about the resident's continued need for the antibiotic.
The nursing director shared infection prevention responsibilities with the facility administrator, though she noted the administrator was not a nurse. V2 said she was supposed to monitor antibiotic surveillance and review residents' antibiotic orders monthly, working with the facility's nurse practitioner to ensure proper medical justification.
That monthly review process appeared to break down across multiple cases.
Resident 14 had been taking Bactrim twice weekly since November 11th for "prophylaxis related to personal history of urinary tract infections." The order contained no stop date. V2 explained the resident "takes Bactrim because R14 apparently has had bad UTIs in the past and she wants to be on it."
The resident had never been diagnosed with an acute UTI while living at the facility. Staff had never collected a urine sample from her during her stay. V2 admitted she had never discussed the resident's continued Bactrim usage with the nurse practitioner.
Resident 15's case illustrated how the facility routinely continued hospital antibiotic orders without medical review. The resident was admitted from a local hospital with a prescription for Nitrofurantoin and discharged on January 9th after a short stay.
"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 (V18 NP) about the need to continue this medication."
The facility's own antibiotic stewardship policy, dated December 2022, requires all antibiotic orders to include specific information including start dates, stop dates, and indications for use. The policy states antibiotics should be prescribed and administered under guidance of the facility's stewardship program.
Three of the four problematic orders lacked stop dates entirely. None included proper medical indications based on current diagnostic testing.
V2 acknowledged that some residents remained on antibiotics prophylactically "because they were admitted with the order or the resident or family just wants them to stay on the antibiotic." This approach contradicted standard medical practice requiring periodic reassessment of antibiotic necessity.
The nursing director said she reviews prophylactic antibiotic orders monthly with the nurse practitioner to ensure medical need and proper diagnosis. However, her interviews with inspectors revealed she had not conducted these required discussions for any of the four residents identified.
Federal regulations require nursing homes to ensure each resident's drug regimen remains free from unnecessary medications. Prolonged antibiotic use without medical justification can lead to antibiotic resistance and other adverse health effects.
The inspection, completed January 29th, found the facility failed to meet this standard for four of five residents reviewed for unnecessary medications in a sample of 17. Inspectors classified the violation as causing minimal harm or potential for actual harm.
The facility's antibiotic surveillance system appeared to exist on paper but failed in practice. Despite written policies requiring proper oversight, the nursing director had not collected basic diagnostic tests or consulted with medical providers about continued antibiotic necessity.
V2's admission that families sometimes requested continued antibiotics, and that the facility complied without medical review, suggested a pattern of prioritizing customer satisfaction over clinical judgment. The practice left residents exposed to unnecessary medication risks while potentially contributing to broader antibiotic resistance problems.
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.