Federal inspectors found three residents at Avante at Lake Worth with missing or inadequate catheter care orders during an October 7 complaint investigation. In each case, the facility's nursing director struggled to explain what care had been provided or produce records showing treatments were completed.
The most glaring example involved a resident who had been readmitted to the facility on September 26 with a catheter that had been inserted about two weeks earlier. When inspectors asked what catheter care orders existed from the readmission date through October 7, the Director of Nursing couldn't provide an answer.
The nursing director told inspectors that all catheter-related orders for this resident were entered on October 7 — the day of the inspection — leaving an 11-day gap with no documented care plan.
"When asked what was done for Resident #2 from 09/26/25 - 10/07/25 the DON was not able to answer," inspectors wrote.
A third resident had been at the facility since September 22, but catheter orders weren't placed until October 7. When asked what happened during the 15 days between admission and the inspection, the Director of Nursing "could not state what happened."
The documentation failures extended beyond missing orders. For one resident, inspectors found catheter care orders that read "Foley Cath care every shift and PRN every 8 hours as needed for prevention." When the nursing director was asked whether this meant care should be provided every shift or only as needed, he said "the orders covered both PRN and every shift care."
But when inspectors asked to see documentation proving every-shift care was being completed, the Director of Nursing couldn't find it. The only documentation available was a PRN section, which was blank.
Pressed on how staff could track whether catheter care was being completed or refused without a way to document it, the nursing director made a startling admission. He "stated he agreed there was no way to keep track of catheter care and was not able to provide documentation of it being completed."
The Director of Nursing acknowledged that another resident's catheter orders were set up correctly, with options to document both every-shift and as-needed care. When asked why all residents with catheters didn't have orders written this way, he couldn't explain the inconsistency.
Catheter care requires meticulous attention to prevent infections and other complications. Standard protocols typically include cleaning around the insertion site, monitoring for signs of infection, and ensuring proper drainage. Without clear orders and documentation, facilities cannot demonstrate that residents are receiving this essential care.
The nursing director described the facility's process for reviewing orders when residents are admitted. "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."
Despite outlining this systematic approach, the same director admitted he was "in charge of making sure orders are started and continued" but acknowledged that "these orders were unfortunately missed."
The phrase "unfortunately missed" understated the scope of the problem. Three separate residents had catheter care issues, suggesting the breakdown wasn't an isolated incident but a pattern of inadequate oversight.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest possible level of well-being. This includes ensuring that medical orders are properly written, implemented, and documented.
The inspection findings revealed a facility where the person responsible for nursing operations couldn't account for basic medical care provided to residents with catheters. The Director of Nursing's inability to locate documentation or explain care gaps raised questions about oversight throughout the facility.
When confronted with the evidence, the Director of Nursing didn't dispute the inspectors' findings. The report noted simply: "The DON agreed with the findings."
For residents and their families, the implications extend beyond missing paperwork. Without proper orders and documentation, there's no way to ensure that vulnerable residents received the catheter care necessary to prevent painful infections and serious medical complications.
The inspection classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents. But for the individuals involved, the lack of documented care represented a fundamental breakdown in the facility's responsibility to provide safe, appropriate medical treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avante At Lake Worth, Inc. from 2025-10-07 including all violations, facility responses, and corrective action plans.