Health inspection·October 7, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review and interview, the facility failed to honor resident preferences for 1 of 4 sampled residents, as evidenced by failure to allow Resident #4 to have an air mattress.The findings included: Review of facility policy titled Avante Mattress Protocol updated June 2022, documented in part.Grade II Intermediate Support Surface: Definition: A powered alternating pressure reducing mattress. Who Do I use it On: 3. Residents non-compliant with turning and reposition and at high risk for skin breakdown with approval from Regional of Clinical Services.Record review revealed that Resident #4 was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, on a 0-15 scale indicating no cognitive impairment. Review of section GG of the quarterly MDS assessment, revealed Resident #4 required maximum assistance to roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed.Review of the care plan dated 07/16/25, revealed a focus that Resident #4 had a ADL (activities of daily living) self-care performance deficit related to decreased mobility and required set-up to total assistance by 1 or more people. Ability varies due to a diagnosis of hemiplegia (paralyzed on one side), obesity, anxiety, generalized weakness, with a goal that she will maintain current level of function. Another focus revealed that Resident #4 had a potential for impairment to skin integrity related to limited mobility, incontinence, with a goal that the resident will maintain clean and intact skin.Review of a wound care visit report dated 09/29/25 documented Resident #4 had nonhealing moisture associated skin damage to the right and left ischium (bone at base of pelvis).During an observation on 10/07/25 at 9:20 AM, Resident #4 was observed in her room, sitting upright in bed wearing oxygen via nasal cannula. No air mattress was noted on her bed.During an interview on 10/07/25 at 11:08 AM, when asked do you still have wounds on your buttocks that are being treated, Resident #4 stated yes. When asked had the wounds gotten better, she stated, No, my daughter is involved now because I have been asking for an air mattress for over a year. Before I went to the hospital last year I had one for almost 6 years and they don't know what happened to it. They couldn't find it when I got back. I feel that the air mattress would have prevented my buttocks from getting worse. My case manager with the insurance company has been trying to get me an air mattress, but the people here at the facility will not give him what he needs to submit the paperwork to the insurance company. I don't understand. I really would like to stay here, but I can't if they will not do what's needed to help me to get better. When asked has the wound care nurse done your wound care already, she stated Yes.During an interview on 10/07/25 at 1:32 PM, When asked if there was a reason why Resident #4 doesn't have an air mattress, the Director of Nursing (DON) stated in the presence of the Wound Care Nurse, She doesn't qualify. She must have a stage 2 or worse pressure wound. When asked, Do you know anything about her insurance regarding submission of paperwork to get her an air mattress, he stated No. During an interview on 10/07/25 on 1:40 PM, when asked how a resident Residents Affected - Few Page 1 of 5 105372 105372 10/07/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few qualifies for an air mattress, the Regional Nurse stated in the presence of the Administrator, All of our mattresses are considered pressure relieving except when they have a stage 2 or greater wound they will receive an air mattress. I know which resident you are referring to because this has been going on for a while, when I was the DON in the facility. We had spoken to the brother regarding the air mattress and from a clinical standpoint he understood that the resident is on a pressure-relieving mattress that is sufficient for the wound that she has, and he seemed to be ok. Every time we speak to Resident#1 about the air mattress she doesn't seem to have an issue. When asked, is there any other reason why she can't have an air mattress, she stated, I'm not sure, I will have to ask the DON, if the physician writes an order for it and specify that the resident needs it then we can order it. When asked does the resident have to have a pressure ulcer, she stated No, not if the doctor orders it. I know that Resident #4 had an air mattress before, but I will have to go back and look to see why she doesn't have one now. During an interview on 10/07/25 at 2:31 PM, when asked are you the Case Manager for Resident #4, he stated, Yes. When asked if he has tried to request an air mattress for the resident, he stated Yes, the insurance provided an air mattress for the resident prior to her going to the hospital and when she returned to the facility, she didn't have it. Since I met her last year, I was informed that her insurance could provide one and we just needed a referral or an order from the facility to provide to the insurance company. I spoke to the previous social worker, the nurse and the new social worker and told them we just need an order or referral, but the response was they didn't know how to get the prescription and asked if I could get it. I told them, I am a case manager, and I can't do that. I asked multiple times if they could please get a prescription. They kept telling me they don't deal with prescriptions. I go to many facilities, and I know that there is a providing physician who can write an order. During an interview on 10/07/25 at 4:00 PM, Resident #4's daughter stated, My mother still does not have an air mattress. I didn't get to look at her wound on the weekend. When asked did you speak to anyone in Administration regarding the air mattress she stated, Yes, I spoke to the Administrator who told me that the wound care nurse was responsible for determining who gets an air mattress. On 10/08/25 at 2:21 PM, during an interview with the Supervisor of the insurance company; she stated, We have tried for a long period of time to get Resident #4 an air mattress and her request for an air mattress was denied by the facility due to facility protocol. The Case Manager has been seeing the resident for about 6 months now. We have spoken with the Administrator on several occasions with a request for a physician order and clinicals to submit to the insurance company to get approval for an air mattress. We even told them that they could submit the information directly to the medical company they use, and the insurance would pay for it. 105372 Page 2 of 5 105372 10/07/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for catheter care for 3 of 3 sampled residents with catheters (Resident #1, #2, and #3).The findings included:1. Review of the record revealed Resident #1 was admitted to the facility 02/13/24 with diagnoses of Paraplegia (a condition characterized by paralysis or loss of movement in both legs) and Neuromuscular Dysfunction Of Bladder (when there is damage or dysfunction in the nerves or muscles that control bladder function.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #1 had a urinary catheter.Review of Resident #1's care plan dated 08/21/25 documented, Resident #1 has (Indwelling Foley) Catheter: Neurogenic bladder with a goal of, Resident #1 will show no signs or symptoms of urinary infection through review date and interventions that documented, Foley Catheter: Foley Cath care every shift and PRN (as needed).Review of the current orders revealed Resident #1 had an indwelling catheter for neurogenic bladder and an order that documented, Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention dated 06/05/25.Review of the TAR (Treatment Administration Record) for September 2025 and October 2025 revealed the order Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention Start Date 06/05/25 was entered as an as needed order with no documentation of catheter care ever being done.During an interview on 10/07/25 at 9:15 AM, when asked how her care was, Resident #1 was visibly upset and stated she did not like how they take care of her urinary catheter and most times she would just take care of it herself. Resident #1 stated she did not trust staff around her private area.During an interview on 10/07/25 at 10:55 AM when asked to observe catheter care, Staff A, Registered Nurse (RN) Unit Manager stated that Resident #1 was very particular on who cleans her private area and sometimes she cleans herself as she often refuses assistance.During an interview on 10/07/25 at 1:26 PM, when asked how would you care for a resident who has a urinary catheter, Staff B, Licensed Practical Nurse (LPN) stated she was a new nurse who had only been working for 2 weeks and hadn't cared for any residents who had urinary catheters yet. When asked if she received any training on how to care for a Resident with a urinary catheter she stated she did not receive any training and had seen a nurse she was training with perform catheter care but that's all she knew.On 10/07/25 at 1:40 PM Staff A was asked how they cared for Resident #1's catheter if she refused the staff's assistance, Staff A stated they would find a staff member she was okay with and stated she would help clean her herself when Resident #1 let her or she would get assistance from her family. When asked if she had received incontinence and catheter care today, Staff A stated she would go check.On 10/07/25 at 2:45 PM Staff A let the surveyor know that that Resident #1 let the staff allow her to get cleaned up and received care. Staff A stated the Residents in the 300 unit had already received catheter care for this shift and would not be performed until next shift, the surveyor requested to observe catheter care next shift and Staff A agreed. The surveyor was not made aware again to observe catheter care during the remainder of the survey time.2. Review of the record revealed Resident #2 was initially admitted to the facility 07/16/25 and re-admitted [DATE] with diagnoses including Fractures to the Right Femur and Neuromuscular Dysfunction Of Bladder. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #2 had a urinary catheter.Review of Resident 105372 Page 3 of 5 105372 10/07/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #2's care plan dated 09/28/25 documented Focus: The resident has indwelling foley catheter related to neurogenic bladder . date created on 10/07/25 with a goal that documented, the resident will be/remain free from catheter-related trauma through review date . date created on 10/07/25. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks PRN, empty catheter bag every shift, observe for pain/discomfort due to catheter, observe for signs and symptoms of discomfort on urination and frequency . date created on 10/07/25. Another section of this same care plan documented, Focus Enhanced Barrier Precautions: The resident is at risk for multidrug-resident organism (MDRO) r/t indwelling medical/Urinary Catheter . date created on 10/07/25; Goal: Minimize risk of transmission of colonized or infection with MDROs . date created on 10/07/25; Interventions: Enhanced Barrier Precautions: Wear gown and gloves during resident high-contact activities in room, therapy gym or shower room[i.e. dressing, bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use; central line, urinary catheter, feeding tube, Inform resident/representative precautions will be in place until the resolution of the wound or discontinuation of indwelling medical device. Restriction to room or limit ability to participate in group activities is not required. Observe for change in condition. Notify MD as indicated. date created on 10/07/25. conducted.Review of Resident #2's active orders related to catheter care documented as followed: Enhanced Barrier Precautions: Indwelling Medical Device every shift for Multiple drug-resistant organism precautions.Maintain Indwelling Catheter Size: 16 FR 10cc Balloon. May irrigate indwelling Foley catheter with 60ml of NS q shift PRN for blockage, occlusion leakage etc. as needed.Change bed side drainage bag of Urinary Catheter PRN as needed for Catheter careChange indwelling Foley catheter when Medically Necessary and PRN as needed.Foley Catheter: Foley Cath care every shift and PRN every shift AND as needed.The above orders were all entered on 10/07/25 at 11:49 AM. The discontinued and completed orders were also reviewed and the only catheter related order was one that documented Change bed side drainage bag of Urinary Catheter PRN Started date of 09/26/25 and end date of 10/7/25.During an interview on 10/07/25 at 4:00 PM, Resident #2 stated she has had the urinary catheter since approximately 09/18/25 and this was the second catheter she has had.3. Review of the record revealed Resident #3 was admitted to the facility 09/22/25 with diagnoses of Acquired absence of other parts of urinary tract; Acquired absence of other genital organ(s) and leakage of other urinary catheter, subsequent encounter. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS indicated Resident #3 had a urinary catheter.Review of Resident #3's care plan dated 09/23/25 documented, Focus: Resident #3 has a suprapubic urinary catheter related to: Bladder removal due to cancer.Review of Resident #3's active order revealed she had a suprapubic catheter (a thin, flexible tube inserted into the bladder through a small incision in the lower abdomen (pubic area) to drain urine. ) The orders documented as followed:Monitor suprapubic catheter for signs and symptoms of infection and leakage. every shift.Cleanse suprapubic catheter with normal saline pat dry. Leave open to air every night shift.May irrigate suprapubic catheter with 60ml of NS q shift PRN for blockage, occlusion leakage etc. every 4 hours as needed for Catheter care.Change indwelling suprapubic catheter when Medically Necessary and PRN as needed.All orders were entered on 10/7/25 at 11:45 AM (the day the survey was conducted.) Discontinued and completed orders were also reviewed and revealed orders for an indwelling catheter which Resident #3 did not have. These incorrect orders were discontinued 10/07/2025.During an interview on 10/07/25 at 4:05 PM, Resident #3 stated she came 105372 Page 4 of 5 105372 10/07/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the facility with her catheter and it was inserted for about 2 weeks now.During an interview with the Director of Nursing (DON) on 10/07/25 at 4:10 PM a side-by-side review of Resident #1, #2 and #3 orders were reviewed.During review of Resident #1's orders, when asked to explain how the order: Foley Catheter: Foley Cath care every shift and PRN every 8 hours as needed for prevention was written (if it was a PRN or a every shift order), the DON stated that the orders covered both PRN and every shift care. When asked to provide the every shift catheter care documentation, the DON was not able to find it. The only documentation available for that order was a PRN section which was also blank. When asked how they keep track of catheter care being completed or refusal if there is not a way to document through the order, the DON stated he agreed there was no way to keep track of catheter care and was not able to provide documentation of it being completed.During review of Resident #2's orders, the DON pointed out to the surveyor, Resident #2's orders for catheter care have the option to document every shift and PRN care and Resident #2's orders should have entered this way. When asked why all Resident #2's catheter related orders were entered today and asked if Resident #2 had catheter orders from 09/26/25 (date of readmission) - 10/07/25, the DON was not able to provide an answer. When asked what was done for Resident #2 from 09/26/25 -10/07/25 the DON was not able to answer.During review of Resident #3's orders, when asked why catheter orders were placed for the Resident on 10/07/25 and what was done for the resident since the admission date of 09/22/25, the DON could not state what happened. When asked what the process of reviewing orders for accuracy was, the DON stated, when the resident comes in, their chart gets broken down and discussed with the clinical team, they make sure the orders are there, make sure they look at diagnosis, and follow up batch orders or re-order what is need. When asked who is in charge of making sure orders are started and continued, the DON stated, I am but stated these orders were unfortunately missed. The DON agreed with the findings. 105372 Page 5 of 5