Health inspection·April 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide blood pressure monitoring to meet the needs of a resident, and failed to assess the accuracy of medication administration, for 1 of 3 sampled residents (Resident #1). Residents Affected - Few The Findings included: A review of the facility's policy on Medication Administration, dated 01/27/2025, revealed medications are administered in accordance with the prescribers orders, and number 11 revealed vital signs are checked and verified for each resident prior to administering medications. 1) Resident #1 was admitted on [DATE] and was discharged on 11/08/24. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, and Heart Failure. A review of the Minimum Data Set (MDS) dated [DATE] under Section C for Brief Interview of Mental Staus (BIMS) revealed a score of 15 indicating good mental cognition. A review of orders dated 11/6/24 at 4:47 PM revealed Spironolactone oral tablet 25 MG, give 0.5 tablet by mouth one time a day for edema, hold if Systolic Blood pressure (SBP) is less than 120. A review of orders dated 11/5/24 at 1:00 PM revealed to obtain and document vital signs every shift for 72 hours, then re-assess for continued monitoring. A review of the Medication Adiministration Record (MAR) dated 11/7/24 at 9:00 AM revealed Spironolactone was given by Staff D, Licensed Practical Nurse (LPN), when she took and recorded Resident #1's blood pressure reading of 86/62 on 11/7/24 at 8:55 AM . A review of Resident #1's docuemnted blood pressire (BP) measurement revealed the following : on 11/7/25 at 8:55 AM, it was 86/62, on 11/7/25 at 10:44 PM, it was 87/68, and on 11/8/25 at 6:54 AM, it was 85/42. A further review of documented BP revealed there was no BP recorded between 8:55 AM and 10:44 PM on 11/7/24, revealing no reassessment for continuing monitoring was done per doctor's order. There was no BP documentation on 11/7/24 between 10:44 PM and 11/8/24 at 6:54 AM revealing no re-assessment for continuing monitoring was done per doctor's order. Page 1 of 3 105506 105506 04/10/2025 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Staff B, LPN, on 04/10/25 at 10:35 AM, when asked how she would manage a resident with a blood pressure of 90/50, she responded, I would know by looking at the resident. The resident would have pale lips or darker blue lips, and the skin feels cold. She added that she would check the vital signs. She would also assess the resident's breathing, skin, bowel movement, and if she thinks something is wrong and the resident does not look ok, she will inform the doctor of resident's low BP. In an interview with Staff D, LPN, on 04/10/25 at 11:32 AM, when asked how she would care for a resident if there was a change in condition, she responded, I would check the resident's vital signs and blood pressure. When asked what would she do if the previous BP was 102/70 and now is 90 /60, she responded, I will call the doctor, and I will check the medications. She would make sure the resident is talking, is safe and responsive to questions in bed, then she will go to the nurses station to call the resident's family and call the doctor. 105506 Page 2 of 3 105506 04/10/2025 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure adequate hydration and nutrition for 1 of 3 sampled residents (Resident #1) Residents Affected - Few The findings included: During a record review of the Facility's policy, titled weight assessment and intervention , it was revealed under evaluation that the physician and the multidisciplinary team identify conditions or clinical situations and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss based on the following examples, medication related adverse consequences, fluid and nutrient loss, and inadequate availability of food and fluids. Resident # 1 was admitted on [DATE] and was discharged on 11/08/24. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, Heart Failure. A review of the Minimum Data Set (MDS) section C for Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating good mental cognition. Section N revealed Resident # 1 was on anticoagulant, antiplatelet and diuretics. A review of Dietary progress notes dated 11/7/24 at 2:37 PM revealed Staff G, Registered Dietitian, notified Medical Doctor (MD) that Resident #1 was noted with increased reflux. Resident #1's daughter rrevealed resident is lactose intolerant. The MD was requested to change Ensure supplement to trial of Ensure Clear. An order by MD included: Pepcid increased to 2x/day; Recommend discontinuing Ensure plus and give Ensure clear daily. Continue to monitor per orem (oral intake and follow up as needed). A review of Nursing progress notes did not include Staff D, LPN monitored the fluid intake of resident on 11/7/24 at 8:55 AM when the blood pressure (BP) of 86/62 was documented. There was no recoded progress notes done by Staff D regarding monitoring of fluid intake when resident is on 2 diuretics, had a low BP. A review of progress notes from the facility's multidisciplinary team did not indicate any nutritional evaluation related to resident's medications such as BP medications and diuretics. An additional review of nursing care plan did not include a focus on fluid and nutrition maintenance and any interventions on how to maintain the resident's fluid and nutrition status. In an interview with Staff A, a Licensed Practical Nurse (LPN), when asked if she monitored resident # 1's fluid status, she responded, she does not remember. In an interview with Resident #1's physician ,on 04/10/25 at 5:30 PM, when asked why he waited for the order of Intravenous fluids until 11/8/24 at 9: 00 AM, he responded, I saw the resident on 11/6/24 and 11/7/24 and she was ok. 105506 Page 3 of 3