Luxe At Jupiter Rehabilitation Center (the)

F-F804.

During an interview on 04/04/25 at approximately 2:00 PM, when told of the numerous cold food complaints,

the Registered Dietitian (RD) stated she was aware of the complaints and had done numerous temperatures

in the kitchen with no concerns identified. The RD agreed it was more than likely due to the trays sitting in

the hallway for an extended time, and possibly due to a staffing issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38212 potential for actual harm Based on record review, policy review and interview the facility failed to obtain an ordered laboratory result Residents Affected - Few for a medication (Depakote) for 1 of 1 sampled Resident (Resident #61).

The findings included:

The facility policy titled, Standards and Guidelines: Physician's Orders, revised on 01/2024 documented in part: Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.

Resident #61 was admitted to the facility on [DATE REDACTED] with diagnoses to include in part Hypertension, Major depressive disorder, Congestive heart failure, Atrial fibrillation, Anemia, Protein calorie malnutrition and a brief psychotic disorder.

On 11/27/24 Resident #61 was ordered 750 mg Depakote Sprinkles by mouth two times a day for mood disorder. The order was changed on 02/13/25 to read Depakote 500 mg 1 tablet two times a day for mood disorder.

The facility has a pharmacist consultant who reviews all the medications for each resident once a month.

This prevents under and over medications of the residents, and possible side effects from their medications.

In January 2025, the pharmacist reviewed Resident #61's medications. The pharmacist had recommendations for the medication, Depakote. Part of the recommendation for Resident #61 was for the physician to order a serum level for the Depakote. The pharmacist stated they were unable to locate a serum level in the chart. The physician agreed and a serum level was ordered to be collected on 02/25 for the medication Depakote.

The medication Depakote has a significant impact on brain chemistry. The right dosage is essential. If too little is given, then the symptoms may not be controlled, and too much of the medication can lead to toxicity.

The laboratory results were reviewed for Resident #61. A Valproic Acid (Depakote) serum level could not be located in the resident's record.

On 04/03/25 at approximately 5:00 PM, the findings were discussed with the ADON (Assistant Director of Nursing) and the Administrator. The laboratory result for the Depakote serum level was unable to be located.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404

Residents Affected - Few Based on observation, interview, and record review, the facility failed to honor food preferences for 5 of 10 sampled residents, Residents #27, #29, #44, #50, and #85, who had food complaints, as evidenced by the failure to follow the meal ticket and menu.

The findings included:

1) Review of the record revealed Resident #27 was admitted to the facility on [DATE REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale.

Review of a dietary progress note dated 02/04/25, documented in part, Resident #27 would like to update her food preferences, to include a chef garden salad with ranch dressing as an entree every Monday, Wednesday, and Friday. A subsequent progress note dated 02/18/25 documented the resident was happy with the updated food preferences. Review of a dietary assessment by the Registered Dietitian (RD) on 02/27/25 revealed the resident now had wounds and nutritional interventions to include fortified foods was added.

During an interview on 03/31/25 at 10:40 AM, Resident #27 stated she had lost 25 pounds and was too thin. Stated she recently spoke with someone and they added a chef salad, which she stated she really enjoyed.

The resident showed the surveyor a recent menu ticket that documented the chef salad. This ticket also documented the intervention of fortified foods. When asked about oatmeal at breakfast, the resident stated

she did not like their oatmeal because they put something in it that makes it gummy. Resident #27 also had

the preference of whole milk at every meal, further stating, I don't always get it, but I'm happy if I get it twice a day. Resident #27 further stated they keep bringing her coffee that she does not like, she prefers hot tea, referring back to her menu ticket.

An observation of Wednesday's lunch meal on 04/02/25 at 1:58 PM revealed Resident #27 did not get her chef salad. Photographic evidence obtained. When asked if she wanted to request one now, the resident provided half of her leftover salad from a previous day and stated, I knew I wouldn't get it so I saved this.

An observation on 04/03/25 at 1:56 PM revealed a chef salad on the tray of Resident #27, although the menu ticket documented chef salad on Monday, Wednesday, and Friday. Photographic evidence obtained.

During an interview on 04/04/25 at 2:06 PM, when shown the photo of the resident's Wednesday lunch meal,

the Certified Dietary Manager (CDM) agreed. When asked why the salad on Monday, Wednesday, and Friday, the CDM stated, Resident preference. The CDM confirmed that anything extra on the menu ticket is resident preference. When told of the resident's complaint regarding the gummy oatmeal, the CDM explained

the oatmeal becomes thicker as it sits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 2) Review of the record revealed Resident #29 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] revealed the resident had a BIMS score of 15, on a 0 to 15 scale, indicating Level of Harm - Minimal harm or he was cognitively intact. This same MDS documented the resident weighed 232 pounds. potential for actual harm

During an observation and interview on 04/02/25 at 2:02 PM, Resident #29 had finished his lunch and Residents Affected - Few complained of the small portion. The resident provided a photo of his lunch meal that he had taken on his cell phone. Photographic evidence obtained. The resident stated that when he gets his money for the month he will need to supplement his intake by ordering some extra food. The resident stated he was a big guy and needed more. Review of his meal ticket documented double protein portion.

During an interview on 04/04/25 at 2:01 PM, when shown the photo of Resident #29's lunch from 04/02/25, both the RD and CDM agreed he was served a regular portion of meat instead of the requested double protein portion.

3) Review of the record revealed Resident #44 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented the resident was cognitively intact with a BIMS score of 13, on

a 0 to 15 scale.

Review of the current order dated 12/29/24 documented Resident #44 was ordered fortified foods at meals.

During an observation and interview on 04/01/25 at 10:19 AM, the activity assistant entered the resident's room to pick up her breakfast tray. Resident #44 stated she was missing her peanut butter and jelly sandwich (PB&J), dry cereal and coffee that morning. The activity assistant stated she would inform the kitchen. Resident #44 stated she really enjoyed the uncrustables (a brand of sandwich) that they started giving her a few weeks ago but then stopped. When asked how often she would like them, the resident stated every morning. Resident #44 confirmed she had not gotten the PB&J sandwich that day or the previous. Resident #44 volunteered she had sugar that morning for her coffee, but no coffee, and milk for her cereal, but no cereal.

An observation on 04/02/25 at 9:49 AM revealed Resident #44 did not receive a peanut butter and jelly sandwich as per her breakfast ticket menu. Photographic evidence obtained. An observation on 04/03/25 at 1:33 PM lacked the chef's soup as documented on her menu ticket. Photographic evidence obtained.

During the continued interview on 04/04/25 at approximately 2:00 PM, the RD stated the residents love the uncrustables and it could be provided to Resident #44. The RD and CDM were shown the meal ticket and breakfast meal without any PB&J sandwich and agreed with the finding.

4) Review of the record revealed Resident #50 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented the resident was cognitively impaired with a BIMS score of 03,

on a 0 to 15 scale. Review of the current orders revealed as of 09/18/23 the resident was to receive both large portions and fortified foods with meals. Review of a progress note dated 12/10/24 by the RD documented the resident agreed to large portions, as he had lost weight in the past. A subsequent note dated 02/24/25 by the RD documented to continue large portions and fortified foods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 An observation on 04/02/25 at 9:39 AM lacked fortified oatmeal. When asked if he wanted the oatmeal, Resident #50 stated, I stopped eating oatmeal as a kid. Level of Harm - Minimal harm or potential for actual harm During a subsequent observation on 04/03/25 at 1:08 PM, a regular sized portion of meat was noted on the resident's lunch tray. When asked if the portion was a large meat portion, the RD shook her head no. Residents Affected - Few Photographic evidence obtained. At 1:26 PM, upon completing the meat provided, when asked if he would have eaten more meat if he had more, Resident #50 stated, I probably would have. When asked if he wanted more at that time, he stated, Not now since I've started my dessert.

During a phone interview on 04/04/25 at 9:04 AM, when asked about the resident's previous weight loss, the resident's wife stated he had lost weight after being in the hospital and was initially put on a pureed diet. She stated when his diet was upgraded, his weight increased as well. The wife stated she would like him to maintain his weight. When asked if he likes oatmeal, the wife stated she had never seen him eat oatmeal, even prior to admission.

On 04/04/25 at 1:52 PM, when asked if she asks residents who are ordered fortified foods if they like oatmeal, the RD stated she typically does, but if the resident had dementia or was asleep, she may not ask.

5) Review of the record revealed Resident #85 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented the resident was cognitively intact with a BIMS score of 12. The resident was noted to have a current weight as of 03/06/25 of 137 pounds and was underweight as per his BMI (body mass index) score of 18.7. The resident had been underweight since admission.

A nutritional evaluation by the RD on 02/03/25 documented the resident desired a gradual weight gain and that interventions would be put into place to include fortified foods.

During an interview on 03/31/25 at 3:38 PM, Resident #85 stated he had lost weight. The resident explained

he was supposed to be on fortified foods and that sometimes his ticket gets messed up. When asked if he has voiced his concerns, the resident stated he tries to speak with the RD about the food and she tells him to call the CDM, who doesn't answer the phone. Resident #85 further stated he doesn't always get his milk and that he received chocolate milk once or twice. Review of the resident's meal ticket documented fortified foods and chocolate milk on Monday, Wednesday, and Friday.

An observation on 04/02/25 at 1:55 PM revealed a lack of any type of milk or fortified foods. Photographic evidence obtained.

An observation on 04/03/25 at 2:04 PM revealed a lunch plate with meat and potatoes. The menu ticket documented, gravy on meat and starch. The potatoes lacked any gravy. Photographic evidence obtained. When asked if he would have liked the gravy on the potatoes he stated, Of course, but I just have to accept what I get at this point.

During an interview on 04/04/25 at 2:09 PM, the CDM stated they did not have any chocolate milk this week, but he was sure the resident had received it in the past. The CDM and RD agreed with the other findings when shown the photos of the meal trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50895 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable Residents Affected - Some and at acceptable food temperatures for 9 residents (Residents #75, #83, #23, #251, #10, #29, #50, #27, and #85) out of 10 residents investigated for food concerns. This had the potential to affect 111 out of 112 residents on PO (by mouth) diets.

The findings included:

1) A record review revealed that Resident #23 was admitted to the facility on [DATE REDACTED]. Her diagnoses included Acute Respiratory Failure with Hypoxia, Sjogren syndrome with Lung Involvement, Irritable Bowel Syndrome, and Gastro-esophageal Reflux Disease. Her diet order dated 03/31/25 was for a Regular diet.

This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE REDACTED] was 15. This indicated that Resident #23 was cognitively intact.

During an interview with Resident #23 on 04/02/25 at 12:30 PM, when asked how her lunch was today, Resident # 23 said that the food was good today for a change. The green beans were cooked enough, and

she could eat them. Usually, they were crunchy. Resident #23 also said that the temperature of the food was hot, and most of the time it wasn't hot.

2) A record review revealed that Resident #75 was admitted to the facility on [DATE REDACTED]. His diagnoses included Heart Failure, Respiratory Failure, Gastro-esophageal Reflux Disease, and he was at risk for malnutrition. Resident #75's diet order as of 03/31/25 was for a Regular diet, with Regular texture, and thin consistency fluids. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) assessment dated [DATE REDACTED] was 15. This indicated that Resident #75 was cognitively intact.

During an interview on 03/31/25 at 4:30 PM, Resident #75 complained and said that every meal was served cold. He added that he voiced his complaint to the nursing aides, to nurses, and to the management.

During an interview with Resident #75 on 04/03/25 at 9:39 AM, the resident said he was served scrambled eggs, waffles soaked in water, grits, and bacon for breakfast. He explained that every item on his meal tray was cold.

3) A record review revealed that Resident #83 was admitted to the facility on [DATE REDACTED]. Her diagnoses included Fracture of Shaft of Left Femur, Atherosclerotic Heart Disease, and Anxiety Disorder. Her diet order dated 02/01/25 was for a Regular diet, that was Regular texture, with Thin consistency fluids.

During an interview conducted on 03/31/25 at 11:41 AM, Resident #83 voiced concern about the food. She said it was not served hot. During an interview conducted on 04/03/25 at 9:45 AM, the resident said she didn't eat breakfast at all. She added that it was cold even after they reheated it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 4) A record review of Resident #251 revealed that he was admitted to the facility on [DATE REDACTED]. His diagnoses included Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, and Muscle Wasting to Multiple Level of Harm - Minimal harm or Sites. This resident's Brief Interview for Mental Status (BIMS) score, per Minimum Data Set (MDS) potential for actual harm assessment dated [DATE REDACTED] was 14. This indicated that Resident #251 was cognitively intact.

Residents Affected - Some During an interview with Resident #251 on 04/01/25 at 5:15 PM, the resident said that it bothered him when

he received cold cabbage, cold meat, or anything that was supposed to be eaten hot.

5) During an interview with Resident #251 on 04/03/25 at 9:50 AM, when asked how his breakfast was this morning, he replied that he loved eggs, but the food was tasteless. Everything was so bland. He said he sent food back to the kitchen and when they brought him a new plate of food, the food was still tasteless. Resident #251 said that he could not eat food without spices. He compared food without spices to eating grass.

6) A test tray was requested from the kitchen on 04/02/25 at 1:20 PM, when the dietary aides had almost finished loading up the meal trays onto the cart for delivery to the 3rd floor. The two surveyors and the RD followed the meal cart to the 3rd floor. The test tray was tested on [DATE REDACTED] at 1:55 PM after the last resident

on the 3rd floor was served. The thermometer was calibrated. The temperatures of the foods were taken, and the foods were tasted. The food was warm. The temperature was acceptable to the surveyors. The surveyors tasted pasta, meat sauce, green vegetables, and peaches. The taste of the pasta and the taste of

the green vegetables was unsatisfactory. These foods may have tasted better if they had some seasoning added. The taste of the meat sauce and the peaches was acceptable.

25404

7) Review of the record revealed Resident #10 was admitted to the facility on [DATE REDACTED]. Review of the current Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale.

During an interview on 03/31/25 at 3:33 PM, when asked about the care and services at the facility, Resident #10 stated his only concern was the food. The resident explained that he eats breakfast in his room and that

the food trays sit out in the hall way too long. During a supplemental interview on 04/01/25 at 9:48 AM, Resident #10 stated the breakfast was an hour late and still cold. When asked what he had, Resident #10 stated, The same thing I always get . eggs and a piece of cold bread thrown on the plate that they call toast.

On 04/02/25 at 9:17 AM, Resident #10 had just received his breakfast meal. He lifted the covering and stated, We've never had this before (as he held up the large portion of bacon). When you are not here I get eggs over easy and a piece of cold bread.

8) Review of the record revealed Resident #27 was admitted to the facility on [DATE REDACTED]. Review of the MDS assessment dated [DATE REDACTED] revealed the resident was cognitively intact as evidenced by a BIMS score of 14,

on a 0 to 15 scale.

During an interview on 04/02/25 at 9:59 AM, when asked the temperature of her breakfast, Resident #27 stated, barely warm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 9) Review of the record revealed Resident #29 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] revealed the resident had a BIMS score of 15, on a 0 to 15 scale, indicating Level of Harm - Minimal harm or he was cognitively intact. potential for actual harm

During an interview on 03/31/25 at 11:29 AM, when asked about the food, Resident #29 stated the food was Residents Affected - Some always cold. The resident stated he had complained about it and they told him they were going to get some type of warmer in the kitchen. Resident #29 stated if they got one, the food is still cold. The resident stated

he eats in his room.

On 04/03/25 at 1:59 PM, when asked about the temperature of his lunch, Resident #29 stated, Not hot, but better. The resident volunteered, I suspect the food is not sitting out in the hall as long this week since you all are here (referring to the State survey team).

Observations during the survey week revealed Resident #29 was usually one of the last resident's served, if not the last.

10) Review of the record revealed Resident #50 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented the resident was cognitively impaired with a BIMS score of 03,

on a 0 to 15 scale. Although Resident #50 was cognitively impaired, the resident was conversational and able to make his needs known.

On 04/02/25 at 9:39 AM, when asked the temperature of his food, Resident #50 stated, It's barely warm.

11) Review of the record revealed Resident #85 was admitted to the facility on [DATE REDACTED]. Review of the current MDS assessment dated [DATE REDACTED] documented the resident was cognitively intact with a BIMS score of 12.

During an interview on 03/31/25 at 3:38 PM, Resident #85 stated his food was always cold. The resident stated he eats all of his meals in his room.

On 04/03/25 at 2:04 PM, Resident #85 stated he had received his meal about 5 minutes prior. The resident stated hot tea was not even warm and potatoes were luke warm. The resident volunteered that his eggs that morning were cold.

12) During an interview on 04/04/25 at approximately 2:00 PM, when told of the numerous cold food complaints, the Registered Dietician (RD) stated she was aware of the complaints and had done numerous temperatures in the kitchen with no concerns identified. The RD agreed it was more than likely due to the trays sitting in the hallway for an extended time, and possibly due to a staffing issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50895

Residents Affected - Few Based on observations, interviews, and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 111 of 112 residents on PO (by mouth) diets.

The findings included:

A. During the initial tour of the Main Kitchen on 03/31/25 at 9:15 AM, accompanied by the Kitchen Manager and the Regional Manager of Dietary, the following was observed:

1. The [NAME] microwave had light and dark brown debris on all sides of the interior of the microwave. The kitchen managers agreed with this finding and said they will clean it up right away.

2. To the right of the coffee station, 2 recessed circular insets were dirty. One had brown liquid on the bottom. The Kitchen Manager wiped it out. The plastic utensil holder close to the round insets had brown residue on the top and spots of black powdery residue.

3. The 2 [NAME] double-door ovens had black and brown residue on the exterior of the front of the ovens. There was a pool of brown fluid on the lower bottom right corner of the oven. [NAME] liquid drippings from

the pool of liquid dripped onto the tiled floor.

4. The reach-in Delfield fridge had 3 plastic cups with fluid in them. They were not labeled. When the Kitchen Manager was asked what kind of juice or fluid was in the cup, the Kitchen Manager said they were thickened fluids. When asked how will the staff would know if a thick fluid was nectar thick or honey thick, the Kitchen Manager said I don't know how thick the fluids are. The Kitchen Manager took the cups of thickened fluid and said they will be thrown out.

5. The interior of Manitowoc ice machine had a thick white substance and a blue substance stuck on the area of the hinges that were directly above the ice.

6. A rack of metal shelves that stored small plastic cups, bowls, and glasses had tan, yellow, and brown residue on the bottom shelf.

7. The floor under the metal shelves was dirty. It had a plastic cap, a round foil cover, paper, and food on it.

B. The nourishment room on the first floor was observed on 03/31/25 at 10:20 AM. The surveyor was accompanied by the Kitchen Manager, and the Regional Manager of Dietary.

1. A 1000 ml bottle of Jevity 1.5 (nutrition formula) was opened with yellow-tan liquid splattered on the exterior of the cap and bottle. Approx 200 milliliters remained. It was not dated to indicate when this item was opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 2. A small Styrofoam cup with a plastic lid was on the shelves inside the door of the refrigerator. An orange disposable coffee cup from McDonald's was next to the Jevity on the shelves inside the door. These items Level of Harm - Minimal harm or were not labeled. potential for actual harm 3. The [NAME] Cottage Cheese was not labeled with a name, a date, or a room number. Residents Affected - Few 4. A brown paper bag of food had no date on it.

A review of the policy title Outside Foods revised 04/30/2024 said that food and beverages will be discarded without a name or date, past package expiration dates, and all perishable items after 3 days.

C) During an observation on 04/02/25 at 11:24 AM, the surveyor entered the kitchen and requested that temperatures be taken for the lunch meal. The garbage pail in the kitchen overflowed with garbage. The lid was not closed. The corporate RD instructed the staff to take the garbage outside immediately. The corporate RD told the surveyor that the garbage pail was in the process of being removed.

D) During an observation on 04/03/25 at 9:17 AM , the surveyor requested to see the ice machine to determine if it had been cleaned up. Upon further observation, and a discussion with the Regional Manager of Dietary, it was discovered that the ice machine had a crack on the left side of the lid close to the door hinge. The Regional Manager of Dietary explained that the white and blue colored substances were used as sealants because of the crack. Rust was observed to the left of the cracked part.

Photographic evidence obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33103 minimal harm Based on interview and review of the client's Arbitration agreements, the facility failed to ensure the Residents Affected - Many arbitration agreement is explained to the resident or representative in a manner they understand (Resident #306), and had a signature from the resident or representative if they agree to the arbitration agreement (Residents #87, #306, and #307). This is for 3 of 3 residents reviewed for arbitration.

The findings included:

During the entrance conference on 03/31/25 at 9:47 AM, the surveyor requested a list of residents that currently reside in the facility since 09/16/19 that entered into a binding arbitration agreement. On 04/02/25

the Surveyor was given a list of residents that had a zero, 1 or 2 next to their name. Further review of the arbitration agreement revealed zero meant that the residents did not sign the arbitration agreement, the #1

they agreed to the arbitration agreement and signed the document one time and the #2 meant they have 2 or more arbitration agreements that they have signed. There are two areas the resident or representative sign.

The first is acknowledgment of understanding of the Arbitration Agreement and the second part is agreeing to the arbitration agreement, and that the resident also received a copy of the agreement. The Surveyor chose three residents that had the number 1 next to their name and were recently admitted to the facility.

A review of Resident #87's medical records revealed this resident was admitted to the facility on [DATE REDACTED]. He has a BIMS (Brief Interview for Mental Status) of 15 out of 15, which meant his cognition is intact. Review of

the Arbitration Agreement had Resident #87's name on the document as well as the name of a resident representative. There is no signature by the resident or representative in both areas that is supposed to be signed, but it documented an electronic signature by a staff representative. During an interview with Resident #87 on 04/04/25 at 1:10 PM, the surveyor asked if anyone from the facility spoke to him about the arbitration agreement. (Surveyor had this resident's documents in hand). The resident stated, he was so drugged up when he came from the hospital that he cannot recall anything. He said he is his POA (Power of Attorney).

A review of Resident #306 medical records revealed this resident was admitted to the facility on [DATE REDACTED]. The resident does not have a BIMS score due to just being admitted but is able to answer all questions asked by

the surveyor. A review of the resident's Arbitration Agreement documents his name on the form. During an

interview on 04/04/25 at 1:20 PM with Resident #306, the Surveyor asked this resident if anyone spoke to him and explained what the Arbitration Agreement was. He stated no. His wife was in the room and she was asked the same question and she stated no. The Surveyor asked the resident if he electronically signed the document agreeing to the Arbitration Agreement. He stated no. Asked if he received a copy of the agreement

he stated no.

A review of Resident #307 medical records revealed this resident was admitted to the facility on [DATE REDACTED]. Resident does not have a BIMS score due to just being admitted . A review of the resident's Arbitration Agreement documents his name on the form along with a Resident Representative. There is no signature from Resident #307 or his Representative in the two required signature areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 106148 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106148 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 During an interview on 04/04/25 at 1:35 PM with the Admissions Director she was asked if she does the arbitration agreements. She stated that the Concierge takes care of them, but she is the one who guided her. Level of Harm - Potential for minimal harm During an interview on 04/04/25 at 1:40 PM with the Concierge she was asked if she does the Arbitration Agreements with the residents. She stated that she does the Admissions Packet and the Arbitration Residents Affected - Many Agreements. The surveyor showed her the list of residents and she stated that it is not the right list. She obtained a list, said the residents that have a 1 next to their name signed the agreement and the one that have 0 next to their name did not sign. The Concierge stated that she does everything on a tablet and showed the surveyor. She gave an example and pulled up a resident and stated this resident refused to sign.

He has 0 next to his name. She stated that she puts a note in that they do not want to sign. The resident and or representative do not sign the document when agreeing to the arbitration agreement. The Concierge just taps each section on the computer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 106148