Avante at Lake Worth: Alzheimer's Patient Lost - FL
The resident had been at the facility for more than two years and was previously considered safe to go outdoors independently. But when she left on August 23rd saying she was going for a walk, staff didn't notice she was gone.
A concerned citizen spotted her near 22nd and 8th Street around 4:36 PM, walking alone and appearing disoriented. The man called police and even contacted Avante Nursing Home directly to ask if they were missing a resident.
Staff told him no one was missing.
When the police officer arrived, the woman identified herself but provided conflicting information about where she lived. She said she was from Puerto Rico and mentioned living in a trailer park or apartment complex near Forest Hill Boulevard. Sometimes she said she lived in a nursing home, other times with her cousin.
She described having a room in "a yellow building" but couldn't provide an address. She couldn't remember the name of her nursing home or give contact information for any relatives.
Police searched her identifying information and found no missing person reports. They dispatched officers to an address on her Florida driver's license, but residents there said they'd lived at that location for 13 years and had never heard of her.
Only after police had been working the case for some time did a nurse from Avante arrive at the scene and identify the woman as their resident. The nurse told police the woman "may have been diagnosed with Alzheimer's or Dementia" but was unsure of her specific medical history.
The nurse explained that the nursing home had conducted a head count only after being alerted by a neighbor about a possible missing resident. That initial head count failed to identify the woman as missing.
When the investigating officer went to Avante to speak with staff, facility personnel acknowledged they needed better security measures. They discussed monitoring the main entrance and implementing enclosed secured outdoor areas for residents.
The resident herself later told investigators she had left the facility looking for her friend who "lived down the hall." She got lost and went outside searching. During the investigation, she said she has Alzheimer's disease.
A cognitive assessment conducted after she returned to the facility showed a BIMS score of 15, indicating moderate to severe cognitive impairment. This was a significant decline from her baseline status, when she had been considered cognitively able to safely enjoy outdoor time without supervision.
The Florida Department of Children and Families opened an adult protection investigation on August 25th. When investigators interviewed the resident two days after the incident, she initially didn't understand what they were explaining about leave-of-absence forms. She told the translator she has Alzheimer's.
After the translator explained again, the resident said she remembered and confirmed she had left the facility looking for her friend, got lost, and went outside searching.
The incident represents a complete breakdown in the facility's monitoring systems. A resident with documented Alzheimer's disease was able to leave the property, walk the streets for hours in a confused state, and interact with police and concerned citizens while staff remained unaware she was gone.
Federal inspectors classified the violation as immediate jeopardy to resident health or safety, the most serious level of harm in nursing home regulations. The designation indicates the facility's failure to monitor residents placed vulnerable people at risk of serious injury, harm, or death.
The case highlights the particular vulnerability of residents with dementia who may appear higher-functioning than their actual cognitive status allows. While the woman had previously been considered safe for independent outdoor time, her declining condition required increased supervision that the facility failed to provide.
Staff acknowledged to police that their security measures were inadequate, but only after a resident with Alzheimer's had spent hours lost and confused on public streets while they remained unaware of her absence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avante At Lake Worth, Inc. from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVANTE AT LAKE WORTH, INC. in LAKE WORTH, FL was cited for violations during a health inspection on September 4, 2025.
The resident had been at the facility for more than two years and was previously considered safe to go outdoors independently.
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.