Federal inspectors found that Avante at Lake Worth denied Resident #4 an air mattress despite requests from her daughter, case manager, and insurance company supervisor spanning at least six months. The facility's own Regional Nurse admitted she knew "which resident you are referring to because this has been going on for a while."
The case manager, who works with multiple facilities, told inspectors he had requested the air mattress repeatedly since meeting the resident 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," he said.
But when he approached facility staff, they claimed ignorance about basic medical ordering procedures.
"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," the case manager said. "I told them, I am a case manager, and I can't do that."
The case manager, who visits many nursing homes, said he knew "there is a providing physician who can write an order." Staff kept telling him "they don't deal with prescriptions."
The resident's insurance company supervisor confirmed the facility's obstruction during an October interview. "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," she said.
The insurance company had 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." They even offered to simplify the process, telling facility staff "they could submit the information directly to the medical company they use, and the insurance would pay for it."
The resident had previously received an air mattress from her insurance before a hospital stay. When she returned to the facility, "she didn't have it," the case manager said.
During the inspection, the Regional Nurse defended the facility's position with contradictory statements. She first claimed "all of our mattresses are considered pressure relieving except when they have a stage 2 or greater wound they will receive an air mattress."
But when pressed about whether residents needed pressure ulcers to qualify for air mattresses, she backtracked. "No, not if the doctor orders it," she admitted.
The Regional Nurse acknowledged speaking with the resident's brother about the air mattress issue "from a clinical standpoint" and said "he seemed to be ok" with their explanation about pressure-relieving mattresses. She also claimed that when staff spoke to the resident directly, "she doesn't seem to have an issue."
Yet the nurse couldn't provide clear answers about the facility's actual policies. When asked if there were other reasons the resident couldn't have an air mattress, she said, "I'm not sure, I will have to ask the DON."
She admitted uncertainty about their own procedures: "If the physician writes an order for it and specify that the resident needs it then we can order it."
The Regional Nurse even acknowledged that another resident had previously received an air mattress but said she would "have to go back and look to see why she doesn't have one now."
The resident's daughter confirmed the ongoing problem during her October interview with inspectors. "My mother still does not have an air mattress," she said.
She had spoken directly with the Administrator, who "told me that the wound care nurse was responsible for determining who gets an air mattress."
The case manager emphasized the absurdity of the situation during his interview. "I asked multiple times if they could please get a prescription," he said. The facility's response remained consistent: they claimed they couldn't handle basic medical ordering that other nursing homes manage routinely.
Federal inspectors cited the facility for failing to provide necessary care and services, finding that staff created bureaucratic obstacles to deny a resident medically appropriate equipment her insurance would fully cover. The violation affected few residents but represented minimal harm or potential for actual harm.
The resident's daughter hadn't been able to examine her mother's wound the weekend before the inspection, leaving the medical necessity of the air mattress unassessed while facility staff continued their months-long pattern of deflecting responsibility for obtaining basic medical orders.
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.