Health inspection·September 4, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. During dinner time the nursing staff became aware the resident was missing, and a staff member went out with her car to search for the resident. When the staff member observed the police vehicle, she drove over to it, and recognized Resident #1.Resident #1 was then returned to the facility by the police and the staff member. The census at the time of the survey was 104 residents. There were 27 residents identified as elopement risk. The facility's administrator was notified of Immediate Jeopardy (IJ) and given the IJ Template on 09/03/25 at 3:35 PM. The Immediate Jeopardy was Ongoing at the time of the survey exit on 09/04/25 at 5:00 PM. The findings included:Review of the facility's policy titled, Policies and Procedures: Elopement, dated 03/02/19, included the following: It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable. This is with the intent of not invading privacy but to identify possible elopement. Definition: Elopement includes when a resident leaves the premises or a safe area without authorization and/or necessary supervision placing the resident at risk for harm or injury.Procedure:1) In the event that any staff member identifies that they cannot find a resident in a place that the resident is anticipated to be, the staff member will alert their supervisor for assistance once affirming that the resident was not signed out on leave.2) The supervisor would assume control of the search.3) The supervisor would alert staff of the identity of the resident and direct designated staff to participate in the search.4) The supervisor in charge of the search will not assume that the resident has left the facility and will:a. Re-affirm if the resident could be out of the facility on an authorized leave or pass by reviewing the facility sign out process;b. Determine if it is prudent to call the Residents family or other visitors if there is a possible concern that the resident was taken out and potentially they did not sign resident out;c. If the resident is not authorized to leave the facility independently, initiate a search of the facility and premises by assigning staff to look in various areas;d. If the resident is not located in a reasonable amount of time, the Administrator and the Director of Nursing (DON), the resident's representative, the Attending Physician, and law enforcement officials will be notified as indicated; ande. If the resident remains unable to be located and or is not authorized to leave the facility independently; Initiate an extensive search of the surrounding area.5) When a missing resident is not located Page 1 of 7 105372 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few within the confines of the facility building, then the supervisor in charge would direct designated staff to participate in an outside facility grounds search, which may include but not limited to the roof of the building, the parking lot, and any outside parked vehicles, etc. Review of the facility's policy titled, Policies and Procedures: Therapeutic Leave, dated 03/02/19, and revised on 04/16/25 included the following: It is the policy of this facility to allow residents to leave the facility for a non-medical visit, thereby known as therapeutic leave. Each resident will be permitted to return to the facility after therapeutic leave, regardless of payment source.Definition: Therapeutic Leave-Resident absences for purposes other than required hospitalization. The facility's Leave of Absence (LOA) policy and procedures was requested on 09/03/25, and the above Therapeutic Leave policy was provided by the Administrator. When asked if the LOA policy and the Therapeutic Leave policy are the same, she stated yes, they do not have a policy specifically for LOA. Record review revealed Resident #1 was admitted to the facility on [DATE] with a re-admission on [DATE], with diagnoses that included Diabetes Mellitus due to Underlying Condition with Diabetic Neuropathy; Cognitive Communication Deficit, Dementia Unspecified Severity, Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Alcohol Abuse with Alcohol-Induced Psychotic Disorder, Polyneuropathy and Chronic Kidney Disease. Review of Section C of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had a BIMS (Brief Interview for Mental Status) score of 06/15, which indicated that she had severe cognitive impairment. Review of previous BIMS assessments revealed Resident #1 never scored a 15/15 (cognitively intact), prior to the elopement on 08/23/25. Prior BIMS scores included: on 06/15/21 it was 12/15 (moderate); on 06/10/22 it was 07/15 (severe); and on 02/24/25 it was 09/15 (moderate). Record review revealed on 08/24/25, the facility filed a Federal Report for Neglect, which documented on 08/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of 9, which indicated cognitive impairment, had not been assessed as an elopement risk, exited the facility and walked outside. Review of the facility's investigation report documented the following timeline of the event from 3:35 PM to 5:41 PM (over the 2 hours when the resident went missing): At 1535 (3:35 PM) Resident #1 walked out of the facility. Receptionist opened the door for the resident.At 1538 (3:38 PM) Man in yellow shirt walked into facility.At 1546 (3:46 PM) Man in yellow shirt comes back into facility.At 1548 (3:48 PM) Certified Nursing Assistant (CNA) comes to the lobby, leaves the facility and walks the neighborhood. Head count started.At 1552 (3:52 PM) CNA returns to the facility; no resident with her. She then states she did not see any elderly lady walking. She will go get her car keys to look.At 1559 (3:59 PM) CNA leaves facility with her car to look around the neighborhood; and returned.At Dinnertime (no exact time noted on the report), a CNA notifies the nurse that Resident #1 has not touched her dinner, and she is not in the room.At 1723 (5:23 PM) The nurse walks to the front of the facility after thoroughly searching the unit.At 1724 (5:24 PM) CNA and the nurse walk out the front door; CNA gets into her car and started driving around the neighborhood.At 1741 (5:41 PM) CNA walks in the facility with the resident; resident was placed on 1:1 supervision.Further review of the facility's investigation report revealed witness statements were collected from staff members involved in the incident. Review of Resident #1's electronic care plans on 09/02/25 revealed Resident #1's care plans included: Impaired cognitive function/dementia or impaired thought processes related to (r/t) Impaired decision making which was initiated on 02/23/24 and revised on 08/05/25; Resident is Spanish-speaking, able to understand and be understood in English, but may prefer to communicate in Spanish at times which was initiated on 08/25/25; and Resident #1 is at risk for further falls r/t Gait/balance problems, seizures, muscle weakness, poly neuropathy, psychotropic medications which was initiated on 07/29/21 105372 Page 2 of 7 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and revised on 08/05/25. Further review of the electronic care plans revealed there was no care plan developed for elopement or that Resident #1 exited the facility without staff's knowledge on 08/23/25. Facility management did not acknowledged that Resident #1 eloped on 08/23/25. This is evidenced by interviews conducted with the Administrator and [NAME] President (VP) of Operations: On 09/02/25 at 10:35 AM the [NAME] President (VP) of Operations came into the conference room to ask the surveyor for details of the complaint. She stated that Resident #1 has a BIMS of 15 and capable of making her own decisions. She stated that they reported it (elopement) out of precaution, however, she does not feel that it should have been reported because the resident has a BIMS of 15 and therefore not an elopement. She then stated, actually, if we had not filed a report, you would not have known about Resident #1 taking a walk independently and returning safely to the facility. On 09/02/25 at 9:21 AM an interview was conducted with the Administrator to obtain her statement and understanding of what occurred on 08/23/25. She stated Resident #1 had a BIMS score of 09/15 and the resident went up to Staff A, weekend receptionist, and told her that she wanted to go for a walk. Staff A opened the front doors and allowed Resident #1 to exit. The Administrator stated after Resident #1 returned to the facility, a reassessment of her BIMS was conducted yielding a score of 15/15. She also stated the BIMS assessment was conducted in the resident's native language (Spanish) and Resident #1 had a BIMS of 15/15 again, indicating that she is cognitively intact and able to make her own decisions. The Administrator stated the resident was asked what happened, why she left without notifying staff and she responded, she went to visit her friend and since the resident has a BIMS of 15, it is not considered an elopement. The Administrator stated the resident was assessed and skin check was conducted with no injuries or concerns. She then explained she was unsure why Staff A did not contact management, perhaps because she was new to the facility; however, Staff A should have confirmed that Resident #1 was capable of walking outside on her own. The Administrator stated that the staff did not contact the police because the staff felt Resident #1 was around the neighborhood and not anywhere else. Review of the current Physician's orders for medications showed that Resident #1's medications included an order dated 10/13/23 for Depakote Delayed Release 250 milligrams (mg) tablet to be given by mouth three times a day for Seizures; an order dated 10/17/23 for Oxycodone HCl 10 mg tablet to be given by mouth every 8 hours for non-acute pain; Gabapentin 400 mg capsule to be given by mouth every 8 hours related to Diabetic Neuropathy dated 09/26/22. Further review of the Physician's orders for medications showed that Resident #1 had an order dated 07/21/25 for Farxiga 5 mg tablet to be given by mouth one time a day for Diabetes Mellitus Type 2; an order dated 08/15/25 for Cymbalta 60 mg capsule delayed release particles, given by mouth two times a day for Depression/Anxiety; an order dated 07/07/25 for Ropinirole HCL 0.25 mg tablet to be given by mouth two times a day for Restless Leg Syndrome. Record review on 09/02/25 revealed Resident #1 had no orders for Leave of Absence (LOA), or to be able to leave the facility unaccompanied. Record review of Resident #1's Cognitive Assessment Note dated 05/02/25 conducted by Staff F, Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed Resident #1 was seen due to the facility requiring a detailed cognitive assessment as Resident #1 is showing behaviors related to memory problems requiring recommendation on the care plan. Further review revealed Resident #1 had consequences on functional areas that included: Impairment in remembering names and numbers of relatives and friends; Impairment in traveling outside the neighborhood, driving, or arranging to take public transportation. In addition, Resident #1 was given The St. Louis University Mental Status (SLUMS) exam in which she scored a 6/30 which indicated severity-Dementia. Staff F documented that Resident #1 appears to have Major Cognitive Disorder of mixed etiology. Review of Resident #1's Psychiatry Subsequent Notes from 05/06/25, 07/01/25, 07/18/25, 105372 Page 3 of 7 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 07/25/25, 08/12/25, and 08/22/25, all documented the following: Thought Process-Somewhat disorganized; Thought Associations-Somewhat loose; Speech- Impaired; Insight and Judgement- Impaired; Orientation-Oriented x2; Recall/Short-term Memory-Impaired; Attention Span/Concentration-Impaired; Fund of Knowledge-Impaired. Review of the Psychiatry Subsequent Notes dated 08/25/25 (two days after the elopement event) documented Resident #1 was alert and oriented x 3 and calm during the interview; and a BIMS assessment was conducted (in English by Staff F, PMHNP) in which she scored a 15/15. Review of Resident #1's Psychiatry Subsequent Notes (Amended) created by Staff F, dated 08/26/25 documented Prior to the last visit, the patient had some confusion observed, possible related to a language barrier and facility instructions and assessment not being provided in the patient's native language, and the patient went out through the front door. Review of Resident #1's Physician Progress Notes created by the Physician Assistant (PA), dated 08/25/25 documented Resident #1 has a complex medical history and was seen today due to exiting the facility and was promptly returned without incident or harm. During time of review resident BIMS is a 15 per Social Worker (SW) when completed in her native language. Resident able to leave LOA with third party following facility LOA protocol. On 09/02/25 at 1:10 PM, Resident #1 was observed standing in the hallway near the Activity Director's office. She was dressed (shirt and pants), had sandals on and her hair was in a ponytail. She was asked (in English) her name, which she was able to state as well as her room number. At this time an interview was conducted with Resident #1, and she was able to respond to the questions correctly. However, she was slightly confused when she wanted to go back to her room and thought her room was in the same hallway (Resident #1's room was on the opposite side of the building). Then Staff B, Activity Director, who also speaks Spanish, assisted the resident back to her room and informed the surveyor that Resident #1 is sometimes confused. On 09/02/25 at 1:15 PM, an interview (in Spanish) was conducted with Resident #1 in her room and she was asked if she goes out for walks often. She stated she does go for walks by herself often because she wants to visit her friend and then she laughed (her friend lives at the facility and in the same hallway). She then stated she was tired and wanted to take a nap. On 09/03/25 at 11:16 AM, an interview (in Spanish) was conducted with Resident #1 regarding the incident that occurred on 08/23/25. She stated that she was going out for a walk to go to her friend's house (this friend is a resident in the facility) but could not recall the exact date or address. She mentioned that she was running to cross the street because it was raining and she was afraid she would get sick. Then, she stated a man in a gray car drove up and asked her if she needed a ride, and asked her where she wanted to go, she stated to her trailer home. Then she said the man told her that there was no trailer park in this area. She remembered the man's name, and he took her to his home and gave her coffee, cookies and yogurt. Resident #1 stated she met a female police officer at the man's house and then a staff from Avante picked her up. When asked if she would be able to come back to the facility on her own, without the staff or the police, she stated she probably could, laughed and then stated that she has been at the facility for 15 years (resident was admitted on [DATE]) and has done it before. She then stated she was not lost she was looking for her trailer home. An interview was conducted on 09/02/25 at 11:33 AM with Staff F, PMHNP, who stated he has been coming to facility for almost 2 years. He stated Resident #1 has Dementia and Bipolar disorder. She is usually cooperative; however, she gets agitated sometimes with her roommate. He stated Resident #1 understands English but prefers Spanish. He stated she had never mentioned to him that she wanted to leave or go out of the facility. He confirmed that Resident #1 has periods of confusion; however, when he spoke with her last week, at that time, she was cognitively intact and able to communicate any concerns. He stated that she spoke about wanting to go see a friend, however, was unable to tell where 105372 Page 4 of 7 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her friend lived. An interview was conducted on 09/02/25 at 3:35 PM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for almost 2 years. She stated that Resident #1 is a little confused, but pleasant and has never mentioned that she wanted to go out to visit a friend, at least not to her. Staff C recalled coming in for her shift around 3:25 pm on 08/23/25; and while doing rounds saw Resident #1 in her room drinking coffee and she spoke with her, however, Resident #1 never mentioned anything about going out or seeing a friend. Staff C then mentioned Resident #1 has a Spanish speaking friend in the same unit (Hibiscus) and they often talk to each other. She stated Resident #1 is active and walks around the facility. She stated that she did not hear the first overhead page and if there was a head count at that time no one let her know. During dinner, one of the aides mentioned to her that Resident #1 was not in her room and she said she would check in the Flamingo unit because Resident #1 is always there as well. However, she did not see Resident #1, then she returned to the Hibiscus unit and started the head count. Staff C stated she then walked to the front desk and asked the receptionist if she had seen Resident #1; the receptionist stated she didn't know who that was. At this time the staff started looking for Resident #1 everywhere and Staff D, Certified Nursing Assistant (CNA), took her car to look for Resident #1 around the neighborhood. When Resident #1 returned to the facility, Staff C stated she asked the resident what happened, Resident #1 didn't mention anything, she was confused, calm and laughing, but unable to say where she went. An interview was conducted on 09/02/25 at 3:59 PM with Staff D, CNA, who stated that she has worked at the facility for over 2 months and knows Resident #1, who had never mentioned wanting to go out for a walk. Staff D stated that Resident #1 does like to visit her friend on the same unit (Hibiscus). She stated that around 3 something PM, there was a page for a head count, she went outside, walked up the street and looked down and saw no one and returned to the facility. The dinner trays are usually at the unit by 4:30-5:00 PM, and at this time Staff C, RN asked her where Resident #1 was; she then grabbed her car keys and rode down to almost the streetlight, passing the park and seeing no one. Staff D then stated as she was heading back to the facility, she was passing a road and noticed a Sheriff's car, turned back around and went up the street, that's when she saw Resident #1 sitting in the garage with the police officer and the owner of the house. The police officer asked Resident #1 if she knew her (Staff D) and Resident #1 stated no at first, however, she then realized who she was. Staff D stated Resident #1 got in the car with her and the police officer followed them to the facility and spoke with the receptionist. Staff D stated she took Resident #1 back to her room and gave her water and her dinner. She stated she did not ask Resident #1 why she was at the man's house, but she overheard Resident #1 mention to another staff member she was going on vacation. Staff D then stated that she feels that Resident #1 is a little confused. A phone interview was conducted on 09/02/25 at 5:58 PM with Staff A, weekend receptionist, who stated she has worked at the facility for about 3 weeks and works every other weekend. She stated that this is her first job in a nursing home. She stated she did not recall seeing Resident #1 walking out of the facility on 08/23/25. She noted she had to watch the video to see what occurred. She confirmed that she never looked at Resident #1 and mistook her for a visitor trying to exit the building. Visitors are to sign in and out, but sometimes the visitors are in a hurry and do not sign out and do not stop by the front desk. Staff A stated that a neighbor came in, she could not recall the time and said that there's someone walking along the outer street, but she did not think it was affiliated with the facility. She then stated that another person came in stating, I think there is someone that is walking that might be from Avante, she has a blue striped dress, who looks lost and confused, and that the woman was walking kind of fast on the main street. She recalled thinking she had not seen anyone wearing a dress; 105372 Page 5 of 7 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few however, she did an overhead page for a head count. Then Staff A said that a nurse came up to her and asked her why she is requesting a head count, and she explained that two people from the neighborhood came in with concerns. At this time, the nurse got in the car and a few minutes later returned and stated she did not find anyone. Staff A thought the nurses had done the head count and found no concerns. Then an hour later a nurse came up to her and asked if she saw Resident #1; and Staff A stated that she was thinking I hope that is not the person that was walking around the streets earlier. She stated she was unclear on the training or if she was going to receive more training, however she had not heard from the facility if they were going to let her go or if she still has a job, at this moment she has been suspended. During an interview conducted on 09/03/25 at 12:22 PM with Staff H, Licensed Practical Nurse (LPN), she stated she has worked at the facility for 4 years. She stated a head count means all residents that are supposed to be at the facility are accounted for. Staff H stated she knows Resident #1, she is a sweet lady, but she is confused. Staff H confirmed that Resident #1 never goes through the front doors, therefore she does feel that she might not know how to return to the facility. During an interview conducted on 09/03/25 at 4:50 PM with Staff I, RN, she stated she has worked at the facility for 9 years. She stated she knows Resident #1 well. Staff I noted that Resident #1 is very friendly, she speaks Spanish but can communicate with her in English with no problem. Resident #1 has some confusion, however, has never exited the facility or gone outside on her own. When asked if she feels Resident #1 would be able to return to the facility on her own. She stated no, someone should guide her back because it is a new environment. During an interview conducted on 09/03/25 at 4:58 PM with Staff J, CNA, who stated she has worked at the facility for 31 years. She stated Resident #1 is nice, she can communicate with her in English with no problem, and she is sometimes confused. Staff J stated Resident #1 has never mentioned to her about wanting to go outside. When asked if she felt that Resident #1 would be able to return to the facility if she went outside; Staff J stated no, she would not be able to come back on her own. On 09/04/25 at 10:18 AM an interview was conducted with Staff K, RN, nurse consultant. She stated that the company had realized that the BIMS assessments were being done incorrectly and they have put in place that only the psych NP will be conducting the BIMS assessments. When asked if she felt that Resident # 1, with a BIMS of 06, would be able to return to the facility on her own; she stated that the BIMS on the MDS were conducted by the previous social worker, and they were not accurate. On 09/04/25 at 11:42 AM, another interview was conducted with Staff F, PMHNP, who stated Resident #1 can walk around the facility independently; however, he could not say yes or no if she could find her way back if she were to exit the facility. He also stated that a resident with a BIMS of 06/15 would be able to go outside, and they may or may not find their way, this depends on the individual. He stated Resident 1 would have LOA rights depending on physician's order, however, someone with a diagnosis of Dementia might need someone to accompany them. He confirmed that even a resident with a BIMS of 15 can get lost in a new environment. He stated he does feel that she would be able to move out of the way if she saw a car coming, however Dementia is tricky, sometimes the resident is here sometimes not. A phone interview was conducted on 09/04/25 at 12:52 PM with the Chief Medical Officer. He stated that he has known Resident #1 for a long time and has been practicing Spanish with her. He stated that he believed that on the day of the incident, she might have panicked and could not remember where she was living, sometimes a change in surroundings can affect their cognitive response. He stated at this time that he will remove her LOA and reassess her mental status and redo her BIMS himself. He also added, if the resident wants to go out of the facility, she will be supervised until he determines the resident is safe to go out on her own. Review of the Chief Medical Officer letter statement received and 105372 Page 6 of 7 105372 09/04/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few signed on 09/04/25 at 3:31 PM included that Resident #1 is a long-term resident at the Lake Worth Facility, who is well known to him. The resident had resided in the facility for more than two years. She had consistently demonstrated the ability to safely enjoy time outdoors without supervision. Her baseline cognitive status had traditionally been that of someone safe to enjoy the outdoors independently. Recently, Resident #1 left the facility stating she was going for a walk. Upon arrival back to the facility, her cognitive status was promptly reassessed, with a BIMS score of 15 documented at this time. Review of the Florida Department of Children and Families (DCF) Adult Protection Investigator (API)'s report, opened on 08/25/2025, revealed the API interviewed Resident #1 on 08/25/2025 at 4:29 PM at the facility. The Adult Protection Investigator (API) showed the resident the form to be completed for LOA, Leave of Absence. The translator asked the resident if she has to fill out the form and she did not know what the translator was explaining to her and said she has Alzheimer's. The translator explained it again and Resident #1 stated oh she remembered now. The resident confirmed she left the facility to look for her friend [NAME] who lived down the hall, she got lost and went outside looking for her. Review of the Palm Beach County Sheriff's Office Offense Report dated 08/23/25 documented the following: On August 23rd, 2025, at approximately 16:36 hours, the Law Enforcement Officer (LEO) responded to a call regarding an elderly female, who was observed walking near 22nd and 8th [ A] Street. The complainant reported seeing the female walking in the area and expressed concern due to her disoriented behavior. He (complainant) stated that he initially checked with the Avante Nursing Home to determine if she was a resident, but staff there reported no missing person.Upon arrival the LEO engaged with the female, who identified herself as [Resident #1] and provided her date of birth . The resident stated she was from [P.R.] and mentioned living in a Trailer Park or an apartment complex near Forest Hill Boulevard. The female appeared confused and provided inconsistent information about her residence, alternating between stating she lived in a nursing home and with her cousin. She mentioned having a room in her name at a yellow building but was unable to provide a specific address.She was unable to recall the name of her nursing home or provide contact information for any relatives. Efforts were made to verify her identity and locate her residence. A search of her identifying information revealed no prior police reports or missing person records. Dispatch identified a possible address which was listed on her Florida driver's license. PBSO district 1 was dispatched to the location to make contact with any individuals familiar with the female. District 1 advised that [Resident #1] is unknown to them and they have resided there for the last 13 years.While waiting to obtain any other leads, a nurse from Avante Nursing Home arrived at the location and identified the female as a resident of their facility. The nurse stated that the female may have been diagnosed with Alzheimer's or Dementia but was unsure of her specific medical history. The nurse explained that the nursing home conducted a head count after being alerted by a neighbor about possible missing resident, however, the initial head count failed to identify the female as missing.The LEO then relocated to Avante Nursing Home to speak with the staff. The facility's staff acknowledged the need for improved security measures, including monitoring the main entrance and implementing enclosed secured outdoor areas for residents. 105372 Page 7 of 7