Avante at Lake Worth, Inc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat 3 of 3 sampled residents in a dignified manner as evidenced by the failure to honor the request to use a shower bed with subsequent non-dignified comments by staff toward Resident #1; failure to speak to and treat Resident #3 in a dignified manner related to requested assistance and food; and failure to speak kindly about residents in a foreign language as heard by Resident #4 who spoke that foreign language.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered medications were provided to 1 of 3 sampled residents, as evidenced by the failure to administer three doses of Medrol 4 mg (milligrams) to Resident #2.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide supervision to prevent an elopement, for 1 of 3 sampled residents reviewed for an elopement (Resident #1). The facility's failure to prevent an elopement placed Resident #1 at a likelihood of serious harm, injury or death. While out of the facility on 08/23/25, Resident #1 got lost, and was assisted by a stranger who called law enforcement. She was confused and could not tell them where she currently lived. The facility was not aware the resident was missing for two hours. Two people came to the facility to inform the receptionist there was a person walking around who looked lost and confused, but the receptionist denied the person was a resident of the facility. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. This had the potential to affect 103 residents who were on oral diets.

Inspectors wroteBased on policy review, observation, record review, and interview, the facility failed to assess for self-administration of medication for 1 of 35 sampled residents, as evidenced by no assessment was completed for Resident #68 to self-administer medication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a resident choice for showers, for 1 of 35 sampled residents (Resident #103).

Inspectors wroteBased on policy review, record review, interview and observation, the facility failed to identify and notify of a change in condition for 1 of 35 sampled residents (Resident #91) as evidenced by no documentation of a change in condition in the medical record.

Inspectors wroteBased on record review and interview the facility failed to ensure a PRN (as needed) psychotropic medication was addressed in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medications, as evidenced by an anti-anxiety medication prescribed to Resident #36 did not have a discontinue date.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to investigate an allegation of abuse thoroughly for 1 of 35 sampled residents (Resident #307).

Inspectors wrote3). Resident #56 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, Alcohol Dependence with Alcohol-Induced persisting Dementia, Unspecified Psychosis, Major Depressive Disorder, and other Persistent Mood Disorders. A record review of Minimum Data Set (MDS) under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 7 indicating Resident #56 had impaired cognitive function. Section N revealed a yes response to antidepressant. A review of physician orders dated 03/05/25 revealed Trazodone Hydrochloride 50 milligram (mg), to give 0.5 tablet by mouth, two times a day for depression. An additional review of orders revealed the behavior code monitoring every shift as needed for behavior. An additional order revealed Memantine Hydrochloride 5 mg, to give 2 tablets by mouth, two times a day for Dementia. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the medications were timely administered for 2 of 6 residents observed for medication passes (Resident #80 and Residetn#409). The facility also failed to follow the physician ordered and prescribed medications for 3 of 38 sampled residents (Resident # 41, Resident #8, and Resident #68).

Inspectors wroteBased on observations, interview, and record review the facility failed to follow their Safe Smoking policy to reassessa resident quarterlyand after a change in condition and failed to update the smoking care plan for 1 of 1 resident reviewed for smoking (Resident #72).

Inspectors wroteBased on observations, record reviews, interviews, policy review, and review of professional standards of practice, the facility failed to maintain acceptable parameters of nutrition status for 1 of 4 residents investigated for nutrition (Resident #307).

Inspectors wroteBased on observations, record reviews, interviews, policy review, and review of professional standards of practice, the facility failed to provide the appropriate treatment for enteral feeding to decrease the risk of complications including weight loss and dehydration, for 1 of 7 sampled residents on enteral feeding (Resident #92).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide tracheostomy care and services consistent with the professional standards of practice for 1 of 1 sampled for tracheostomy care (Resident #64); failed to obtain oxygen orders for 2 of 6 residents (Resident #408, and Resident #308); and failed to follow orders for oxygen therapies for 3 of 11 residents receiving oxygen (Resident #7, Resident #23, and Resident #66).

Inspectors wroteBased on interviews and record review the facility failed to maintain completed dialysis communication records for 1 of 1 resident sampled for dialysis (Resident #90).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued controlled medications were removed from the medication carts, and initials and time matched on the MAR and control sheet, for 3 of 10 residents reviewed for controlled medication storage (Residents #91, #20, #97).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a medication cart was secured for 1 of 5 medication carts (Flamingo unit). The facility also failed to ensure medications are secured at bedside for 2 of 35 samplef residents (Resident #68 and Resident #8).

Inspectors wrote2). Resident #409 was admitted on [DATE] with diagnoses including Absence of Epileptic Syndrome Intractable without Status Epilepticus, Metabolic Encephalopathy, Hyperlipidemia and Obstructive and Reflux Uropathy. A review of the admission Minimum Data Set (MDS) under Section C revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #409 had good mental cognition. During a medication pass observation on Flamingo Medication cart 1 with Staff E, a Registered Nurse (RN) on 05/28/25 10:45 AM, it was observed that her computer screen produced a pink color on the 9:00 AM medications for Resident #409. When Staff E , an RN was asked what the pink color meant, she responded, I am administering the medications later than the scheduled time. She added that medications must be administered one hour before and one hour after the scheduled time. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow Enhanced Barrier Precaution (EBP) guidelines for a resident with sacral wounds and failed to initiate a care plan for a resident on EBP for 1 of 25 residents on EBP (Resident #408). The facility also failed to follow the manufacturer's recommendation for disinfection and storage of glucometer (Resident #73 and failed to follow the professional standards regarding glucose strip storage for 1 of 2 observation of glucose monitoring (Resident # 97).

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean and comfortable environment for 3 of 3 sampled Residents (Resident #2, Resident #3 and Resident #4).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care is provided such care, for 3 out of 5 sampled residents with tracheostomy (Resident #3, #2, and #4) and failed to ensure trach tube at bedside for 2 out of 5 sampled residents for tracheostomy (Residents #4 and #5).

Inspectors wroteBased on observations, interviews and record review, the facility failed to wear Personal Protective Equipment (PPE) mask appropriately when providing trach suctioning for residents on Enhanced Barrier Precautions (EBP) for 1of 1 resident observed for tracheostomy suctioning (Resident #5) and failed to ensure PPE (including disposable gowns) was readily available for 9 out of 9 residents with tracheostomy and failed to have EBP signage on door for resident with trach and PEG tube (Resident #3).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure sufficient fluid intake and tube feeding to maintain proper hydration for 1 of 4 residents sampled for tube feeding (Resident #2).

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain a complete and organized medical record for 1 of 3 residents reviewed for respiratory care (Resident #1).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that ponteitiall effected 75 of the facility's residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide maintenance and housekeeping services to maintain a clean, sanitary and home like environment for 17 of 29 rooms on the Hibiscus unit (Rooms #100 to 128), 6 of 17 rooms on the Dolphin Unit (Rooms #200 to 222), 3 of 3 unit corridors and the common areas that included the Activities/Dining area, lobby/reception area, the laundry, and corridors leading to the units from the lobby/reception area.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure reasonable efforts to accommodate individual food preferences, dietary needs, and food quality related complaints for 9 sampled residents that include: Resident's #22, #32, #39, #46, #49, #51, #56, #57, #66, and one resident who requested to stay anonymous.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to honor a residents choices for being out of bed for 2 of 4 residents sampled for choices (Residents #37 and Resident #56); failed to honor resident's choice for eating in the Dining room for 3 of 4 residents reviewed for choices (Resident #56, Resident #22, and a resident that wished to remain anonymous); and failed to honor residents choices for showers for 1 of 4 residents sampled for choices (Resident #38).

Inspectors wroteBased on record review and interview, the facility failed to notify representative for change of condition for 1 of 4 residents sampled for hospitalizations (Resident #9) and 1 of 3 residents reviewed for falls (Resident #12).

Inspectors wroteBased on observations, interviews, and record review the facility failed to close privacy curtain during wound care for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide privacy during medication administration for 1 of 4 residents observed for medication administration (Resident #4).

Inspectors wroteBased on observation, interview, and record review, it was determined that 1 (Resident #79) of 10 sampled residents for nutrition review failed to be given the appropriate treatment of supervision and adaptive eating equipment with meals to maintain or improve ability to eat independently.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide 1 (Resident #19) of 10 sampled residents who are unable to carry out activities receives the necessary services to maintain good nutrition.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide ongoing activities program for 4 of 4 residents, Residents #56, 22, 37, and a resident that wishes to remain anonymous.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice to ensure that 1 (Resident #31) of 2 sampled residents for dialysis review with meals prior to leaving for dialysis appointments and bagged lunches to take to dialysis treatment appointments; failed to provide 1 (Resident #98) of 2 sampled residents with physician ordered pain medication; and failed to provide a consult for 1 (Resident #48) of 2 residents reviewed for physician ordered dermatology consults.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory equipment was stored in a manner to prevent infection for 2 out of 3 sampled residents for respiratory care (Residents #155 and #60).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that 1 (Resident #31) of 2 residents reviewed for dialysis did not receive services consistent with professional standards of practice that included ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide sufficient staffing to accommodate resident's choices for being out of bed, to accommodate residents' participation in activities, and choices for having meals in the dining room. The insufficient staffing has the potential to affect all residents in the facility, including Residents #22, 56, 37 and a resident who wished to remain anonymous. The census at the time of the survey was 108 residents. 1). The Facility Assessment, most recently updated on 01/30/24, did not address the staffing needs to provide activities based on the facility census and the acuity of the residents being provided care. A review of the Activities Calendar for the month of February 2024 revealed the following: Each Sunday, the only activity is Bible Study at 2:45 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to identify medications that were not supposed to be crushed for a resident with a PEG tube for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #18).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 10%, 3 medication errors were identified while observing a total of 30 opportunities, affecting Residents #4 and #60.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility's approved menu was not prepared in advance and not followed and not reviewed by the facility's dietitian or other qualified nutrition professional, for potentially 75 facility residents.

Inspectors wroteBased on observation, interview, and record review, it was determined facility foods were not palatable and not prepared by methods that conserve nutritive value, flavor, and appearance for potentially 75 of 75 of the facility's residents.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a consistency designed to meet the needs of 6 (includes Resident #12) physician ordered pureed diets.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate and complete medical records for 2 of 34 residents in the final sample (Residents #29 and #92).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer medications in a safe and sanitary environment for 1 of 4 residents observed for medication pass (Resident #4); failed to ensure medications are stored in a sanitary manner for 1 of 4 medication carts; failed to provide wound care in a sanitary manner for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide care for laceration in a sanitary manner for 1 of 34 sampled residents (Resident #31).

Inspectors wroteBased on observation and interview, the facility failed to ensure a low air loss mattress was functioning for 1 of 2 residents reviewed for wound care (Resident #20).

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate wound care for 2 of 3 residents reviewed, who were admitted with wounds (Resident #1 and Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutrition (Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to medicate a resident for pain as ordered for 1 of 4 resident reviewed for pain (Resident #1).

Inspectors wroteBased on Facility Policy, observation, record review and interview the facility failed to initiate isolation precautions for 4 of 4 residents reviewed for Transmission Based Precautions (Resident #293, #298 , #68 and #82), failed to maintain oxygen equipment in a sanitary manner for 4 of 7 residents reviewed for Respiratory Care (Resident#26, #28, #71 and #296), and failed to maintain suction equipment in a sanitary manner for 1 of 1 residents reviewed for suctioning (Resident #50).

Inspectors wroteBased on facility policy, record review and interview the facility failed to follow physician's orders for diagnostic tests in a timely manner for 2 of 3 residents reviewed (Resident #71 and Resident #298).

Inspectors wroteBased on observation, interview, policy, and record review the facility failed to provide care and services to ensure resident safety (Resident #20 and #89) and failed to provide supervision to prevent accidents and adequate evaluations post fall (Resident #71) for three of four residents reviewed.

Inspectors wroteBased on observation, records review, and interviews, the facility failed to follow Physicians' orders to ensure 1 of 30 sampled residents (Resident #143) received a dietary supplement.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication as physician ordered for one of three residents reviewed (Resident #18). The resident missed seven doeses, and there were discrepancies in the documentation.

Inspectors wroteBased on Facility Policy, observation, record review and interview the facility failed to have a physician's order for oxygen administration for 2 of 7 Residents reviewed for oxygen administration (Resident #71 and Resident #296)

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in a sanitary manner, with the potential to affect all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a certified nursing assistant was included in the care plan development process, for 6 of 26 residents reviewed for care plan conference (Residents 14, 17, 25, 46, 52, and 85). Finding Include: On 10/06/22 at 11:00 AM, the electronic medical records (EMR) for Residents #14, 17, 25, 46, 52, and 85, were reviewed. It was noted there was no documentation found that the certified nursing assistant (CNA) participated in the development of the residents care plan. On 10/06/22 at 1:00 pm, an interview was conducted with the MDS Nurse, she was asked to provide evidence of the (CNA) participation in the care plan development process. She stated there was no documentation that the certified nursing assistant participated.