Advanced Care Center failed to ensure proper specialist referrals for Resident #5, who was admitted with Type 2 diabetes, chronic kidney disease, and bladder dysfunction requiring an indwelling catheter, federal inspectors found during an October 23 complaint investigation.
The breakdown began October 8 when Staff G, an advanced registered nurse practitioner, ordered a voiding trial to see if the resident could urinate without the catheter. Her progress note was clear: "If voiding trial fails reinsert indwelling foley and consult urology."
Nothing happened.
Five days later, Staff G documented her frustration: she had given verbal orders the previous Friday for the voiding trial, "but it was not done for unknown reasons." She spoke again with nursing staff and the Director of Nurses about the plan, requesting the trial be conducted and emphasizing that if it failed, they needed to consult urology.
The resident failed the voiding trial on October 20. Despite electronic records suggesting otherwise, Resident #5 had not voided and required straight catheterization, producing more than 400 milliliters of urine. A culture revealed a yeast infection.
Still no urology referral was made.
The Director of Nurses told inspectors that Staff G "wanted Resident #5 to start a voiding trial" because she lacked justification for the catheter use. "When we conducted the trial, the resident failed," the DON acknowledged. "The Nurse Practitioner noted to consult urology if Resident #5 failed the trial, but she did not put an order in the system."
When the DON contacted Staff G about the failed trial, the nurse practitioner's response was different than what the DON claimed. "The DON said when she reached out to the ARNP she told them to just leave the foley in," according to the inspection report. The DON then shifted responsibility, saying "the ARNP could have put the urology consult order in the system if she wanted Resident #5 to be seen by urology."
Staff G disputed this account entirely. She told inspectors she had written the voiding trial order specifically because the resident had acute urinary retention documented in their medical record. "She told the nurse and the director of nurses twice if the resident failed the voiding trial to consult urology."
When the DON called to report the resident wasn't voiding and they had obtained 2,000 milliliters of urine through catheterization, Staff G said her instructions were unambiguous: "she told the DON they needed to get a consultation from urology."
The nurse practitioner explained the standard process to inspectors: "once she gave the facility a verbal order they should have put the urology consult order in the system." She had communicated the same message to multiple staff members. "She told the Unit Manager on Friday and told the DON again on Monday to consult urology for Resident #5."
Her final instructions were explicit: "leave the foley in and consult urology."
The facility's own records confirmed Staff G's version. A summary dated October 23 showed an active verbal order: "Consult Urology for urinary retention." The order existed but had never been acted upon by nursing staff.
Advanced Care Center lacked any written policy or procedure regarding care consultation and referrals, inspectors noted. Without clear protocols, verbal orders from medical practitioners were apparently subject to interpretation or dismissal by nursing supervisors.
Resident #5's case illustrates the consequences of communication breakdowns in medical settings. The resident entered the facility with multiple serious conditions, including stage 3A chronic kidney disease and bladder dysfunction requiring catheterization. When a medical professional determined specialist evaluation was necessary, administrative barriers prevented appropriate care.
The inspection classified the violation as causing minimal harm or potential for actual harm to residents. But for Resident #5, the delay meant continued reliance on catheterization without specialist assessment of underlying bladder problems, potentially complicating their diabetes management and kidney function.
Federal inspectors found the facility failed to provide appropriate treatment according to medical orders, violating basic standards for resident care. The case affected few residents but highlighted systemic problems in how Advanced Care Center handles medical referrals and follows physician instructions.
The October 23 inspection was conducted in response to a complaint, suggesting someone recognized the facility's failure to provide proper medical care warranted federal scrutiny.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Care Center from 2025-10-23 including all violations, facility responses, and corrective action plans.