JUPITER, FL - A state health inspection at Luxe at Jupiter Rehabilitation Center uncovered significant violations affecting resident care, including failure to monitor critical psychiatric medication levels and widespread problems with food service that left multiple residents receiving cold, incorrectly prepared meals lacking prescribed nutritional supplements.
Missing Laboratory Tests Put Residents at Risk
The facility failed to obtain ordered laboratory results for a resident taking Depakote, a powerful psychiatric medication that requires careful monitoring to prevent serious health complications. The resident had been taking the medication since November 2024 for mood disorder management, yet when the facility's consulting pharmacist reviewed medications in January 2025, no serum level tests could be located in the resident's chart.
The physician ordered a Depakote serum level test to be collected on February 25, 2025, following the pharmacist's recommendation. However, when state inspectors reviewed records in April, the test results were nowhere to be found. The facility's Assistant Director of Nursing and Administrator confirmed they could not locate the laboratory results.
Depakote requires precise dosing to be effective and safe. The medication works by altering brain chemistry to stabilize mood, but maintaining the correct blood concentration is critical. When levels fall too low, the medication becomes ineffective at controlling psychiatric symptoms, potentially leading to mood instability, behavioral issues, or psychotic episodes. Conversely, excessive levels can cause toxicity, resulting in liver damage, pancreatitis, or severe neurological effects including confusion and seizures.
Standard medical protocol requires regular blood monitoring for anyone taking Depakote, typically every three to six months once stable levels are achieved, or more frequently when initiating therapy or adjusting doses. The therapeutic range is narrow - generally between 50 to 125 micrograms per milliliter - making monitoring essential for both safety and effectiveness.
Widespread Food Service Failures Affect Resident Nutrition
Nine of ten residents interviewed reported persistent problems with meal service, including cold food and failure to receive prescribed dietary supplements and preferences documented in their care plans. The issues affected residents across multiple units and meal services throughout the inspection period.
Temperature Problems Compromise Food Safety
Multiple residents reported consistently receiving cold meals, with some stating "every meal was served cold." During breakfast service observations, residents described receiving eggs, waffles, grits, and bacon that were all cold. One resident noted that even after kitchen staff attempted to reheat meals, the food remained cold.
The facility's Registered Dietitian acknowledged awareness of numerous cold food complaints. While kitchen temperature checks showed no concerns, she agreed the likely cause was "trays sitting in the hallway for an extended time, and possibly due to a staffing issue."
Food temperature control is essential for both safety and nutrition. Hot foods must be maintained above 135°F to prevent bacterial growth that can cause foodborne illness. Cold foods compromise not only palatability but also nutritional intake, as residents are less likely to consume unappetizing meals, potentially leading to weight loss and malnutrition.
Nutritional Interventions Not Provided
Several residents with documented weight loss and nutritional risk did not receive prescribed dietary interventions. A resident who was underweight with a BMI of 18.7 was ordered fortified foods to promote gradual weight gain. However, observations revealed the resident did not receive fortified items or the chocolate milk specified for Monday, Wednesday, and Friday delivery. The Certified Dietary Manager acknowledged they "did not have any chocolate milk this week."
Another resident ordered double protein portions due to weight of 232 pounds received regular-sized servings instead. When shown photographic evidence, both the Registered Dietitian and Certified Dietary Manager confirmed the portion was incorrect.
Fortified foods contain additional calories, protein, vitamins, and minerals crucial for residents at nutritional risk. Missing these supplements can accelerate weight loss, decrease wound healing capacity, and weaken immune function. For elderly residents, inadequate nutrition directly correlates with increased falls, pressure ulcers, infections, and extended recovery times.
Personal Preferences Ignored
The facility repeatedly failed to honor documented food preferences, affecting residents' quality of life and nutritional intake. One cognitively intact resident who requested chef salads three times weekly as an entree did not receive them on scheduled days. When she didn't receive her Wednesday salad, she showed inspectors half of a leftover salad from a previous day, stating "I knew I wouldn't get it so I saved this."
Another resident's breakfast ticket specified peanut butter and jelly sandwiches, dry cereal, and coffee, but observations over multiple days showed these items missing from meal trays. The resident reported receiving "sugar for her coffee, but no coffee, and milk for her cereal, but no cereal."
Kitchen Sanitation Concerns
Inspectors documented multiple sanitation issues in food preparation and storage areas that could contribute to foodborne illness risk:
The kitchen's microwave contained "light and dark brown debris on all sides of the interior." Coffee station areas showed brown liquid pooled in recessed insets with black powdery residue on nearby utensil holders. Commercial ovens displayed black and brown residue on exteriors with brown fluid pooling that dripped onto the floor below.
The ice machine presented particular concerns, with "thick white substance and a blue substance stuck on the area of the hinges directly above the ice." Staff later revealed these substances were sealants applied to address a crack near the door hinge, with visible rust adjacent to the damaged area.
In the nourishment room, inspectors found an opened bottle of nutritional formula with dried liquid on the exterior that lacked required dating to indicate when opened. Multiple unlabeled items in the refrigerator violated the facility's own policy requiring all perishable items be labeled with names and dates.
Additional Issues Identified
Beyond the major violations, inspectors documented problems with the facility's arbitration agreements. Three recently admitted residents' agreements lacked required signatures despite electronic records indicating acceptance. One resident and his wife stated no one explained the arbitration agreement to them, they never electronically signed it, and never received a copy as required by regulations.
The facility's Concierge responsible for admissions paperwork indicated she simply "taps each section on the computer" rather than obtaining actual resident or representative signatures when processing arbitration agreements, potentially violating residents' rights to understand and voluntarily enter such agreements.
Pattern of Systemic Failures
These violations reveal systemic breakdowns in multiple critical areas of resident care. The failure to monitor psychiatric medication levels demonstrates inadequate medication management systems and follow-through on physician orders. The widespread food service problems indicate insufficient staffing, poor quality control, and lack of responsiveness to resident complaints despite management awareness of ongoing issues.
The kitchen sanitation deficiencies and damaged equipment remaining in service suggest deferred maintenance and inadequate food safety protocols. Together, these findings paint a picture of a facility struggling to meet basic standards of care across multiple departments, potentially compromising resident health, safety, and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Luxe At Jupiter Rehabilitation Center (the) from 2025-04-04 including all violations, facility responses, and corrective action plans.
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