Advanced Care Center: Urology Referral Delayed for Weeks - FL
Federal inspectors documented the failure on October 23, 2025, after reviewing the medical records of a resident identified only as Resident 5. She had been admitted with Type 2 diabetes, neuromuscular bladder dysfunction, chronic kidney disease at stage 3A, and an infection tied to her indwelling urethral catheter. Her condition was already complicated before anyone started debating who was responsible for picking up the phone.
The plan, written into a progress note on October 8 by Staff G, an Advanced Registered Nurse Practitioner, was straightforward: attempt a voiding trial, and if the resident could not pass it, remove the catheter, consult urology. Five days later, Staff G documented that the voiding trial had not been done. Nobody knew why.
Staff G wrote in her October 13 note that she had spoken with nursing staff and the Director of Nurses about the plan. She repeated the instructions. Try the voiding trial. If she fails, consult urology.
By October 20, the resident had failed the voiding trial, though the electronic records initially showed otherwise. Staff G's note corrected that: Resident 5 had not voided on her own. Straight catheterization produced more than 400 milliliters of retained urine. Lab results came back positive for yeast.
The urology consult still had not happened.
When inspectors interviewed the Director of Nurses on the afternoon of October 23, the DON said the nurse practitioner had never entered a formal order into the system. "The ARNP could have put the urology consult order in the system if she wanted Resident 5 to be seen by urology," the DON told inspectors. The DON said that when she reached out to Staff G after the failed voiding trial, Staff G told them to just leave the foley catheter in place.
Staff G told a different story.
Interviewed an hour and a half later, the ARNP said she had communicated the urology referral plan twice, once to the Unit Manager on a Friday and again to the DON the following Monday. She said she had given the facility a verbal order. "Once she gave the facility a verbal order they should have put the urology consult order in the system," inspectors summarized. Staff G said she told both the Unit Manager and the DON to consult urology if the resident did not pass the voiding trial, and that her instructions were to leave the foley in and consult urology, not to simply leave the foley and move on.
The order summary dated October 23, the day inspectors arrived, finally showed a urology consult order in the system, listed as active. It had been more than two weeks since Staff G first documented the plan.
The DON and the ARNP each described the other as the person who should have acted. The inspection record does not resolve whose account is accurate. What it shows is that a resident with a documented bladder condition, a catheter infection, and a lab result positive for yeast went without a specialist evaluation while the two clinicians most responsible for her care pointed in opposite directions.
Inspectors also found the facility had no policy or procedure governing care consultations and referrals.
The violation was cited at a level of minimal harm or potential for actual harm. Whether Resident 5 ultimately saw a urologist, and what a specialist found when she did, is not recorded in the inspection report.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ADVANCED CARE CENTER in CLEARWATER, FL was cited for violations during a health inspection on October 23, 2025.
Federal inspectors documented the failure on October 23, 2025, after reviewing the medical records of a resident identified only as Resident 5.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.