Inspection visit

InspectionMarch 28, 2024

JUPITER REHABILITATION AND HEALTHCARE CENTERCMS #10555515 citations on this visit

15 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) A medication pass observation with a random resident, who asked to remain confidential, was made on 03/27/24. Upon entering the room, the surveyor introduced herself and explained she was observing the nurse. The resident stated, The nurses are great, but you need to check up on the CNAs (Certified Nursing Assistants). On 03/27/24 in the afternoon, when asked what was meant by check up on the CNAs, the random resident stated, Some are great, but some have such attitudes. They don't care. I treat them with respect and expect the same from them, but don't always get it. The resident stated, Some act as if they don't want to be here. I know it's a tough job, but it is their job. And they don't let us know they are the CNA for the shift. The resident explained that the nurses come around at the beginning of each shift and let them know they will be the nurse for the shift. Review of the record revealed the resident was cognitively intact, as per a recent Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale. 5) During an interview on 03/25/24 at 12:19 PM, Resident #159 voiced the staff speak to each other in another language, in front of her, which makes her feel as if she is not there. The resident voiced the CNAs have talked about her outside of the room and have not been kind. During a supplemental interview on 03/27/24 at 3:28 PM, Resident #159 was visiting with her family. The resident volunteered that two CNAs had closed her curtain and door, and that she had muted her TV, and heard them say, That (resident's last name) and son . a pain in the [ ]! Resident #159 also stated that she had had today's nurse several times, and today was the first time that she introduced herself, referring to earlier in the day when the surveyor had done a medication pass with Staff L, Registered Nurse (RN). The resident and family stated the staff don't care, don't make eye contact, and are rude. During an interview on 03/28/24 at 12:07 PM, accompanied by the Risk Manager, Resident #159 and her family vented for about 15 to 20 minutes about the attitudes of the staff. The family voiced that staff were complaining about being short-staffed and overworked. They stated staff won't help with her colostomy bag. They described how last evening they had asked an RN three times for assistance, as the colostomy bag had become loose and was leaking. The family described how the RN told them three times he would get to it, yet he was seen at the nurse's station laughing with staff and playing on his cell phone, not helping them. The son stated he finally just got a new colostomy bag, and they assisted his mother and to change the bag. Both the resident and the son again stated that staff said they are a pain . and they are not going to help her again, referring to assisting her up in the bed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 27 Event ID: 105555 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Review of the Admission/readmission Evaluation dated 03/22/24 documented Resident #159 was alert and oriented to person, place, and time, with no memory or behavioral issues. 6) During an interview on 03/27/24 at 1:01 PM, Resident #161 was still unshaven, as observed that morning. When asked what was going on with his request to shave, Resident #161 stated the staff told him he had to wait. Resident #161 then volunteered, The girls (referring to the CNAs) are just rude. I put on the call bell, and they don't answer. I have to call out for them, and they just walk by my door and ignore me. I had to get the maintenance guy to hand me my phone. The resident explained that his phone had been on the bedside nightstand, behind him and out of reach. Review of the record revealed Resident #161 was admitted to the facility on [DATE]. Multiple skilled services nursing notes documented Resident #161 was alert with no memory issues. Resident #161 was observed to be obese with bilateral lower extremity edema (swelling) and needed assistance with activities of daily living. Based on observation interviews, the facility failed to ensure 7 out of 29 sampled residents were treated with respect and dignity regarding care and dining assistance (Resident #25, Resident #212, Resident #50, Resident #159, Resident #161, Resident #73, and Resident #60 and two Anonymous residents). The findings included: The facility's policy for 'Dignity' revised February 2021, documented: Each Resident shall be cared for in a manner that promotes and enhances his or their sense of well-being, level of satisfaction with lie, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. 1) On 03/25/24 at 10:20 AM, Resident #25, who is documented to have a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment) stated, The [ ] aides have no compassion; they are rude and don't treat us right. This resident's spouse (Resident #212), who was also his roommate and has a BIMS score of 15 (intact cognition), came into the room at the end of the interview and stated that she agreed with Resident #25's statement concerning the rudeness of some of the certified nursing assistants (CNAs), as she also had experienced the CNAs' rudeness and disrespect at times. On 03/27/24 at 12:30 PM, an additional interview was conducted with Resident #25 and Resident #212. Resident #25 stated that he did not appreciate the way the aides had treated his wife during her shower that morning. When interviewed on 03/27/24 at 12:35 PM, Resident #212 stated, When giving me a shower this morning, the aide didn't wait for the water to get warm. She just poured water over my head and sprayed me in the face without any warning; she wasn't very considerate. The wife also added, When something is said to them [the aides] they get nasty. They also roll their eyes at us whenever they are asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 2 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0550 to do anything for us. Level of Harm - Minimal harm or potential for actual harm 2) On 03/25/24 at 10:40 AM, a Resident who wanted to remain anonymous stated, The nurses have been great, and half of the aides are very good, but the other half do not want to provide assistance. I am at the end of the hall, and some of the aides act like those of us down here at the end are not part of the facility; they mostly ignore us. It would be nice to be treated like everyone else instead of like an inconvenience. I have fallen a couple of times because I try to do things on my own. Residents Affected - Some 3) On 03/25/24 at 10:28 AM, Resident #50, who has a BIMS score of 8 (moderate cognitive impairment), stated during her initial interview, Some of the staff are very good, but some of them are very bossy. They like to order me around. This morning, I told them that I didn't want to eat because I wasn't hungry, and the aide kept telling me I had to eat. Sometimes, I just don't feel hungry, and I don't want to eat, but she told me I had to eat. I try to do what they say because I don't want to make them mad. 7) Resident #73 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual Minimum Data Set (MDS), dated [DATE], documented Resident #73 had a BIMS score of 06, indicating that the resident was severely cognitively impaired. The MDS documented that Resident #73 was dependent upon staff for eating. During an observation of lunch served to the residents in their rooms on the 300 unit, on 03/25/24 at 12:58 PM, Staff C, CNA, was observed removing a tray from Resident #73. At that time, another staff member asked Staff C why the tray was being removed from the resident's room. Staff C replied, he is a feeder. When the surveyor asked about the meal being removed from the resident, Staff C again replied, he is a feeder. During an observation of breakfast served to the residents in their rooms on the 300 unit, on 03/26/24 at 8:35 AM, Staff D (CNA), was observed standing at Resident #73's right side of bed to feed resident. When asked about using a chair to sit and feed the resident, Staff D stated I am short, and I have trouble reaching the food on the table. During the observation Resident #73's bed was in a raised position. 8) Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #60 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS documented that Resident #60 required 'Supervision or touching assistance' for eating. Resident #60's diagnoses at the time of the MDS included: Anemia, Quadriplegia, Traumatic Brain Injury, Malnutrition, Cognitive Communication Deficit, COPD (Chronic Obstructive Pulmonary Disease), Dysphagia, and History of Healed Traumatic Fracture. During an observation of lunch served to the residents in their rooms on the 300 unit, on 03/25/24 at 1:04 PM, Staff C, CNA was observed standing to the resident's left side of the bed with lunch on the residents over bed table that was positioned between Staff C and the resident. Staff C was observed reaching over the table to feed the resident, dropping portions of the meal on the resident's upper left chest. During the observation, there was a room chair positioned to the resident's right side of the head of his bed. During observations of Resident #60 eating in his room, for breakfast on 03/26/24 and 03/27/24 and lunch on 03/27/24, Resident #60 consumed more than 75% of the meals independently with the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 3 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0550 adaptive equipment from his overbed table, and without dropping any of the food on himself or his bed and surrounding area and equipment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 4 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor preferences for 3 of 8 sampled residents (Resident #159, #161 and #74). The facility failed to respond to a verbal request for side rails to assist with bed mobility for Resident #159. Shower preferences and schedules were not followed for Resident #161 and #74. The findings included: 1) During an interview on 03/25/24 at 12:19 PM, Resident #159 stated she had been asking for a bed side rail since she was admitted to the facility. The resident stated she wanted it to assist her with turning in bed and that she had been asking everyone for it. Observation of the bed at that time lacked any type of side rail or mobility device. During a supplemental interview on 03/27/24 at 3:28 PM with the resident and her family, they all confirmed the resident had been asking for a bed side rail since day one. Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Review of the Admission/readmission Evaluation dated 03/22/24 documented Resident #159 was alert and oriented to person, place, and time, with no memory issues and no behavioral issues. Further review of this admission evaluation simply documented the resident was able to move in bed with or without side rails. During an interview on 03/27/24 at 3:14 PM, when asked the process should a resident want a bed side rail installed, the Maintenance Director stated the nurse has to do an evaluation, and then the request would need to be put into TELS (the electronic system for entering maintenance requests). When asked about Resident #159, the Maintenance Director stated, She wants one? When told she had been asking staff for a bed side rail since her admission on [DATE], the Maintenance Director stated he would check his maintenance requests. The Director later stated he did not have a request for Resident #159. Both Staff L, Registered Nurse (RN), who had worked with Resident #159 for several days, and Staff P, Certified Nursing Assistant (CNA), during separate interviews on 03/27/24 around 3:20 PM, denied any knowledge of the resident's request for side rails. During an interview on 03/28/24 at 12:07 PM, the family of Resident #159 asked the Risk Manager why it took the surveyor's intervention to get the side rails for his mother. 2) During an interview on 03/25/24 at 10:01 AM, upon introduction, Resident #161 stated, I've been asking for a shower since 6 AM. Upon further questioning, Resident #161 explained he was admitted on Friday (03/22/24) and he had also been asking for a shower all weekend. During a supplemental interview on 03/25/24 at 2:41 PM, Resident #161 was still dressed in his hospital gown and stated he hadn't had a shower yet. Resident #161 stated, First they said after breakfast, then they said after lunch, and it's now almost 3 PM. Review of the record revealed Resident #161 was admitted to the facility on Friday, 03/22/24, was alert, and had no memory issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 5 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Task section of the electronic record documented Resident #161 was scheduled for showers on Wednesdays and Saturdays during the 3 to 11 PM shift. This task section documented the provision of a shower on that Monday, 03/25/24, during the 3 to 11 PM shift. During an interview on 03/26/24 at 9:45 AM, Resident #161 confirmed he received his first shower at the facility the previous evening. When told it looked like he was scheduled for showers on Wednesdays and Saturdays during the 3 to 11 PM shift, Resident #161 stated he was not told that information. During a side-by-side record review and interview on 03/28/24 at 1:54 PM, the Director of Nursing (DON) stated her task report documented Resident #161 received a shower on Saturday 03/23/24 and on Wednesday 03/27/24. The DON was told that was not what was reported by the resident. 3) Record review revealed Resident #74 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after being sent via 911 to the hospital related to respiratory failure. According to Resident #74's most recent full assessment, an Annual MDS, dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status score of 14, indicating that the resident was cognitively intact. The assessment documented that the resident required 'supervision or touching assistance for showering and transfers. Resident #74's diagnoses at the time of the MDS included: Heart failure, Hypertension, GERD (Gastroesophageal Reflux Disease), Neurogenic Bladder, Hyperlipidemia, Arthritis, Non-Alzheimer's Dementia, Seizure Disorder, Anxiety disorder, Depression, Chronic Lung Disease, Respiratory Failure with Hypercapnia, Atelectasis, Pain in Left Shoulder, IBS (Irritable Bowel Syndrome), Acidosis, Insomnia, SOB (Shortness of Breath), Esophageal Obstruction and Diabetes. Resident #74's care plan for Activities of Daily Living (ADLs), initiated on 12/22/21 with a revision date of 04/12/23, documented, Resident requires assist with activities of daily living which may fluctuate related to Physical and Health condition Acute and Chronic Respiratory Failure with Hypercapnia, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), Bronchospasm, Decrease Mobility and Weakness. The goal of the care plan was documented as, Resident's ADL status will improve through the review date with a target date of 06/12/24. Interventions: o Encourage resident to participate to the fullest extent possible with each interaction. o Chair/bed to chair transfer: (4) Supervision or touching assistance required o Lying to sitting on side of bed: (6) Independent - No supervision or set up / clean up required. o Sit to lying: (6) Independent - No supervision or set up / clean up required. o Sit to stand: (4) Supervision or touching assistance required. o Toilet transfer: (4) Supervision or touching assistance required. o Walk 10 feet: (4) Supervision or touching assistance required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 6 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0561 o Tub / Shower transfer: (4) Supervision or touching assistance required. Level of Harm - Minimal harm or potential for actual harm o Shower / bathe self: (3) Partial / moderate assistance required X 1 staff Residents Affected - Few During an interview on 03/26/24 at 9:55 AM, Resident #74 stated that she had not had a shower since returning from the hospital 03/05/24. Review of Resident #74's ADL task worksheet for the previous 30 days revealed the following: Resident #74's shower schedule is Tuesdays and Fridays on the 11PM to 7 AM shift. Resident #74 received showers on 03/14/24, 03/20/24, and 03/22/24. Resident #74 received Bed Bath on 8 occasions. Resident #74 received Sponge bath on 3 occasions. There was no documentation of Resident #74 refusing bath/shower. During a follow up interview with Resident #74, on 03/28/24 at 11:53 AM, Resident #74 stated that she was not aware of the shower schedule. Resident #74 stated, the CNA on that shift doesn't like me, he only brings me water every once in a while. I go in there with my soap and washcloth and wash in the sink. I would prefer to have a shower, but I am not allowed to without someone with me. I know I have to go in their range between breakfast lunch and dinner. At home, I used to take a shower before bed every night. During an interview, on 03/28/24 at 12:01 PM with the MDS Coordinator, when asked about residents being assessed for preferences, the MDS Coordinator replied, therapy sets the ADL tasks. Nursing assesses the residents for preferences on admission. During an interview, on 03/28/24 at 12:05 PM, with Staff G, UM/RN (Unit Manager/ Registered Nurse) when asked about honoring a resident's preference for showers, Staff G replied, we have a schedule for showers. It is done by room and twice per week. Rooms would be scheduled on a certain day and on a certain shift. We can accommodate residents' preferences. When Staff G was informed about Resident #74's preferences for showers and the lack of showers provided to the resident, Staff G stated that she would reassess Resident #74 for her shower preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 7 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to consider the views of the resident council group and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility for 9 of 9 sampled residents interviewed during the Resident Council meeting (Resident #47, #45, #8, #10, #58, #63, #33, #70, and #7). This failure has the potential to affect all residents in the facility, as the resident council represents all residents. Residents Affected - Some The findings included: On 03/27/24 at 11:01 AM, interviews were conducted with 9 active, alert and oriented members of the Resident Council (Resident # 47, #45, #8, #10, #58, #63, #33, #70, and #7). The 9 resident council members were asked about the facility's response to grievances voiced by members of the Resident Council during their monthly meetings. All of the resident council members agreed that several grievances were voiced during the monthly Resident Council meetings, but none of these grievances had been resolved by the facility's administration. Three of the council members who wished to remain anonymous stated that when they have tried to bring up concerns to Administration, they were told, If you don't like it, you can find another place to live. Residents #58, #45 and #63 stated they were tired of voicing their concerns because none of the concerns ever got resolved. None of the 9 members of the council could recall a time when staff had responded to their concerns, explaining how their concerns were being addressed and/or resolved. Per interview with the 9 Resident Council members listed above, some of the grievances voiced during monthly resident council meetings that had not yet been addressed/resolved were: 1) Chairs needed for showers - The council members stated there used to be a chair for over-the-toilet and a chair placed in the shower for those needing to sit during showers. Resident #58 stated, Now there is only one chair that has to be moved back and forth from toilet to shower, and it usually requires for us, the resident to move it. This isn't safe. The administrator was informed of this issue about 2 months ago, and nothing has been done. 2) Cold food - All of the 9 council members interviewed complained that the food carts brought to the units will sit in the hallways for 1/2 an hour before staff will pass the trays, and by the time the residents get the food, the food is cold. 3) More food variety - Each of the council members interviewed wanted more food variety on the menu, including fresh fruits and vegetables. Resident #45 stated, We have asked for fresh fruits and vegetables, but we are still getting canned fruits and vegetables. 4) Laundry bags - Resident #58 stated that they used to have laundry bags provided which had their name and room number on them; however, these bags have been taken away. Now they have plastic bags with nothing written on them. I have brought up this concern several times, but nothing has been done. How do they know which laundry bag belongs to who? This is how clothes go missing. A review of the Resident Council Minutes from October - March 2024 did not reveal all of the concerns voiced by the 9 members of Resident Council on 03/27/24. When these members were asked why their concerns were not recorded in the resident council minutes, the resident council members stated they did not have an answer as to why. Resident #58 stated, I don't know why they aren't in the minutes, but I know I have went directly to the Administrator and voiced the concerns about the chairs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 8 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0565 laundry bags. Level of Harm - Minimal harm or potential for actual harm A review of the Grievance Log from October 2023 - March 2024 noted only 1 grievance documented for Resident Council in November of 2023. This grievance was related to food concerns, and it was documented that the concern was resolved on 11/17/23. Residents Affected - Some Another grievance regarding menu and food quality was filed on 12/13/23 by Resident #58, one of the Resident Council members. The Grievance Log documented that the food grievance was resolved on 12/14/23. Resident #58 stated that the food issues mentioned in the grievances have not been resolved, and the other 9 council members agreed. Resident #58 did add, The food has gotten better, but there are still issues that need to be addressed. On 03/27/24 at 11:50 AM, the Activities Director confirmed that she did attend the Resident Council meetings and took the minutes for the Council President. On 03/28/24 at 6:15 PM, the Administrator was informed of the concerns voiced by the Resident Council regarding the failure to resolve the council's grievances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 9 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 3 of 4 units (100 Unit, 300 Unit and 400 Unit). The findings included: In room [ROOM NUMBER], the room smelled of urine. It was difficult to tell from which bed the urine smell was coming from. The urine smell was strong around each of the 3 beds in the room. The floor appeared to be dirty and there was debris observed underneath bed B. In room [ROOM NUMBER], the vinyl on the arms of the resident's wheelchair in bed B was cracked and partially missing. In room [ROOM NUMBER], the surface of the foot board of bed A was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surfaces of the headboard, foot board and nightstand to the resident's right side of the bed was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surface of the over bed table for bed A was worn in such a manner that the particle board underneath the surface was exposed and there was a residue under bed A . In room [ROOM NUMBER] the overbed table for bed B was worn in such a manner that the particle board underneath the surface was exposed. In room [ROOM NUMBER], the footboard of the vacant bed C was worn in a manner that the material underneath the surface was exposed. The surface of the overbed table was worn in such a manner that the particle board underneath the surface was exposed. In room [ROOM NUMBER], there was an accumulation of dead roaches behind the closet and the nightstand of bed A. In room [ROOM NUMBER], the pole that was being used to hang tube feeding supplements and intravenous medications was encrusted with residues of bed B. In room [ROOM NUMBER], upon opening the valve for the hot water at the hand sink in the resident's room, there was a loud noise coming from the plumbing. In room [ROOM NUMBER], the clock on the wall that was opposite of the residents' beds did not display the correct time. It was noted that the hands on the clock had not moved for the duration of the survey. During an environmental tour of the facility, on 03/28/24 at 2:02 PM, accompanied by the Maintenance and Housekeeping Director, the Maintenance and Housekeeping Director acknowledged understanding of the concerns. During the tour, Resident #31, in room [ROOM NUMBER] B, stated that he was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 10 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0584 use the remote control for the television due to his poor vision and did not have dexterity in his hands to operate the remote control. Resident #31 also stated that the mattress on his bed felt like it had a hole in it. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 11 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an interview on 03/25/24 at 12:04 PM, Resident #13 was asked how she was doing. The resident volunteered, I have a problem with my roommate. She has her TV or some kind of constant noise from 6 AM to 11:30 PM. I have new hearing aids that I can't wear because she is too noisy. When asked if she had told anyone of her problem, Resident #13 stated, I've told everyone. When asked if she had been offered a room change, the resident stated she had not. During a medication pass observation on 03/27/24 at 3:37 PM, Staff M, Registered Nurse (RN) stated to Resident #13, I'm sorry you had a rough night last night with the TV. Resident #13 looked at the surveyor and stated, I think I may consider your offer of a room change. Review of the record revealed Resident #13 was admitted to the facility on [DATE], and transferred into her current room on 02/17/24. The resident's roommate had occupied the other bed since 01/02/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale. Review of all social services notes lacked any documentation related to a roommate conflict or request to change rooms. Further review of the progress notes revealed Resident #13 had complained to Staff N, the Advanced Practitioner Registered Nurse (APRN) on 02/26/24 regarding the roommate's TV being too loud. The note documented the APRN assisted the resident out of the room to help calm her down. This note discussed modifying the frequency of her anti-anxiety medication, but lacked any documentation related to a room change. A progress note dated 03/26/24 at 10:26 PM by Staff M, RN, documented the resident verbalized feeling anxious because her roommate would not comply to her demands to turn the television down. During an interview on 03/28/24 at 10:49 AM, Staff N, APRN, recalled Resident #13 was upset about her roommate's TV in the past, and thought they had discussed a room change, but the resident had refused. During an interview on 03/28/24 at 1:57 PM, the Director of Nursing (DON) stated she thought they had offered Resident #13 a room change. As per the Admissions Director, the only request for a room change for Resident #13 was late on the previous day. Based on observation, interview and record review, the facility failed to: 1) Ensure that all voiced grievances made by residents to staff are put in writing on a grievance form and submitted to the appropriate person for resolution for 9 of 9 resident council members interviewed; 2) Ensure all written grievances include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 9 of 9 resident council members interviewed; 3) Ensure prompt efforts are made to resolve grievances voiced by 1 of 1 resident who had concerns regarding the roommate's television being on all day and night (Resident #13). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 12 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0585 The findings included: Level of Harm - Minimal harm or potential for actual harm The facility's Policy and Procedure for Grievance/Complaints, Recording and Investigating, published 03/08/23, states: Residents Affected - Some All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). 1. The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. 2. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. 3. The department director(s) of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway. 5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint (if available). c. The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available). d. The date the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or interested party, was informed of the findings; and g. The disposition of the grievance (i.e. resolved, dispute, etc.) 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within ____ working days of the filing of the grievance or complaint. 10. Copes of all reports must be signed and will be made available to the resident tor person acting on behalf of the resident. 1) On 03/27/24 at 11:01 AM, interviews were conducted with 9 active, alert and oriented members of the Resident Council (Residents # 47, #45, #8, #10, #58, #63, #33, #70, and #7). The 9 resident council members were asked about the facility's response to their voiced grievances. Each of the 9 residents stated that they were not aware that a grievance form had been completed in response to any of their voiced grievances, and they never saw a grievance form. None of these 9 residents listed above were able to state who the facility's Grievance Officer was or where the grievance forms were located. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 13 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0585 Level of Harm - Minimal harm or potential for actual harm Each of the 9 Resident Council members listed above confirmed that none of the concerns brought up in Resident Council, or voiced to Administration, were responded to in writing, or otherwise, to include the grievance statement, steps of the investigation, summary of pertinent findings or conclusion regarding the resident's concern(s), whether the concerns were confirmed or not confirmed, and what, if any corrective action(s) was/were taken. Residents Affected - Some A request for the Grievance Log for all grievances filed over the past 6 months (October 2023 - March 2024) was made to the Administrator at the time of entrance on the first day of the survey (03/25/24). The Grievance Log provided by the Administrator only noted 1 grievance documented for Resident Council in November of 2023. Another grievance regarding menu and food quality was filed on 12/13/23 by Resident #58, one of the 9 Resident Council members interviewed. The members of the council, including Resident #58 confirmed that they were not informed of the findings of any investigation into the grievances filed, nor were they told what corrective actions were being done to resolve the issue, as per the facility grievance policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 14 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to update care plans related to nutrition interventions for 1 of 29 sampled residents (Resident #60), and Hospice status for 1 of 29 sampled residents (Resident #43). The findings included: 1) Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #60 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS documented that Resident #60 required 'Supervision or touching assistance' for eating. Resident #60's diagnoses at the time of the MDS included: Anemia, Quadriplegia, Traumatic Brain Injury, Malnutrition, Cognitive Communication Deficit, COPD (Chronic Obstructive Pulmonary Disease), Dysphagia, and History of Healed Traumatic Fracture. Resident #60's dietary Orders included: Regular diet, Mechanically Altered Ground texture, Nectar Thickened Liquids consistency - Fortified foods TID (three times per day) - 08/01/23 with a revision date of 10/25/23. Majic Cup-TID-12/14/23. Resident #60's care plan, for nutrition, initiated on 10/08/20 with a revision date of 07/14/23, documented, Resident at high nutrition risk due to multiple health complications such as HTN (Hypertension), Traumatic Brain Injury, Dysphagia, Cataract, Contracture of Upper/lower Extremities, COPD, Quadriplegia, Alcohol abuse, Muscle Spasm, Constipation, Mechanical altered diet, Thickened liquids, requires assistance for feeding and hydration, history of enteral nutrition , history of PEG (Percutanous Endoscopic Gastrotomy) placement, history of coccyx wound, and history of significant weight loss. The goals of the care plan included: o The resident will maintain adequate nutritional status as evidenced by maintaining weight, or gradual weight gain towards IBW (ideal body weight), no signs/symptoms of malnutrition, and to consume at least 75% of 3 meals served. Date Initiated: 10/08/2020 Target Date: 04/15/2024. o Patient will tolerate prescribed food and fluid consistency well, as evidenced by no signs/symptoms of choking and/or aspiration through goal review date. Date initiated on 07/14/23 with a target date of 04/15/24. Interventions to the care plan included: o Diet: Ground, Nectar Thick Liquids o Provide magic cup BID (twice per day) (580 calories, 18 gm protein per day) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 15 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0657 o Provide, serve diet as ordered. Monitor intake and record every meal. Level of Harm - Minimal harm or potential for actual harm o Registered Dietitian to evaluate and make diet change recommendations PRN (as needed). o Weigh per protocol Residents Affected - Few During an observation of lunch served to the residents in their rooms, on 03/25/24 at 12:56 PM, it was noted that Resident #60 did not receive the majic cup supplement, as ordered. During an interview, on 03/25/24 01:22 PM, with Staff C, CNA, when asked about the resident receiving the magic cup per order, Staff C replied, He only gets the majic cup at breakfast. Review of Resident #60's Medication Administration Record (MAR) revealed that staff had documented that Resident #60 consumed 100% of the supplement that was never provided to the resident during the meal. During an interview, on 03/27/24 at 10:42 AM, with Staff E, LPN (Licensed Practical Nurse) since 2020, when asked about the orders for 'majic cup TID, Staff E replied, They usually get them on their tray at breakfast, lunch and dinner. It comes from the kitchen on the trays. When asked about documenting consumption of the meals and the supplements, Staff E replied, We get the information from the CNA related to consumption, I didn't see if he got it (referring to Resident #60 receiving the supplements as ordered). Nothing was reported in the morning. He gets it for lunch. During an interview, on 03/27/24 at 10:55 AM, with the Registered Dietitian, when asked about documenting the consumption of food and supplements the Registered Dietitian replied, the amount consumed includes just what is on the tray. Supplements are documented in the MAR. the Registered Dietitian confirmed the order for Resident #60's supplements were three times per day. When the Registered Dietitian was made aware of the resident's order not being accurately reflected in the care plan and staff not following the order or the care plan, the Registered Dietitian acknowledged the findings and stated that the resident's care plan would be updated. 2) Record review revealed that Resident #43 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses included: Non-Alzheimer's Dementia, Parkinson's disease. Record review revealed care plans start revision date 02/23/24 and completion revision date 03/12/24, indicated that Resident #43 was long-term care, and he was in the facility under hospice care. Resident #43 was at risk for falls related to physical decline- impaired cognition with poor safety awareness -weakness- on hospice care- diagnosis Parkinson's. Resident #43 was at risk for pain related to chronic Illness, decrease in Mobility-on Hospice care terminal diagnosis Parkinson's. Current physician orders lacked evidence for hospice services. Subsequent review of the clinical records evidenced a physician order created on 01/24/23 for clarification: admitted to [name of company] Hospice on 09/21/2022. Discontinued hospice service on 08/10/23. On 03/27/24 at 1:20 PM, an interview was held with Staff R, a license practical nurse who was attending to Resident #43. An inquiry was made regarding whether the resident was under hospice services Staff R stated, When he first came in, he was on hospice then he graduated his was actually a full code. On 03/28/24 at 9:21 AM, an interview was held with Staff A, the MDS Coordinator. A side-by-side review of Resident #43's care plans was conducted. When inquired about the resident's status, whether (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 16 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0657 he was on hospice services. Staff A stated, He came off hospice on 08/10/23. The care plan should have been updated to reflect his current status. He is still long term, but not under hospice services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 17 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 observation, interview, and record review, the facility failed to thoroughly investigate a fall for 1 of 2 sampled residents (Resident #13) reviewed for falls. The findings included: Review of the record revealed Resident #13 was admitted to the facility on [DATE], and was transferred to her current room on 02/17/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented Resident #13 had a history of a fall with a fracture prior to her admission, and that she needed partial to moderate assist for both toileting and walking. A fall risk assessment dated [DATE] documented the resident was at moderate risk for falls. Review of the current care plan initiated 01/29/24 documented the resident was at risk for falls and staff were to provide toileting assistance as per the resident's needs and therapy recommendations. Review of a progress note dated 03/25/24 at 3:52 AM by a night nurse documented, While call light was ringing, CNA (Certified Nursing Assistant) went to answer the call light and found the resident lying on the floor in her bathroom. Skin assessment was performed, Right elbow skin tear noted. Resident assists back to bed with two assists. Vital signs measured within normal limit. Neuro (neurological) checks initiated. Family member notified. Md (physician) Notified. During an interview on 03/25/24 at 12:04 PM, Resident #13 stated she had a problem with her roommate's TV being on all day and night. The resident stated her roommate turned on her TV last night, in the middle of the night and woke her up. Resident #13 continued to explain that she then got up to go to the bathroom, fell, hurt her elbow, and hit her head. During an interview on 03/25/24 at 12:19 PM, Resident #159, who shared a bathroom with Resident #13, volunteered Resident #13 fell last night in the bathroom and hit her head hard on the floor. Resident #159 stated she had a picture, and pulled up a photo on her cell phone of a resident, who appeared to be Resident #13, on the bathroom floor face up, holding her head. The bathroom light was on. Resident #159 stated she was on the floor for like two hours and they did not call an ambulance. Observation revealed the angle of the photo was such that more than likely Resident #159 had taken the picture from her own bed. When asked, Resident #159 confirmed she had taken the photo from her bed as the bathroom door had been left open. Upon request for the fall investigation of 03/25/24 for Resident #13, Staff G, Registered Nurse (RN) and Unit Manager provided a form titled Fall 03/25/24 at 3:00 AM. This form documented the same progress note written by the night nurse. It also documented the resident stated, While I went to use the bathroom, I lose my balance and I felt. The form documented the resident was alert, and oriented to person, place, situation, and time, utilizes a walker, and that no injuries were observed. Predisposing physiological factors included gait imbalance, blood pressure medication, weakness, and use of anti-depressant. Root Cause Analysis was documented as the resident was observed on the floor in the bathroom. The resident was alert with a BIMS of 15, stated she woke up and went to the bathroom without asking for assistance. Resident #13 was last seen by the assigned nurse 30 minutes prior to the fall and was in bed sleeping. The resident denied any pain or discomfort. Head to toe assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 18 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with skin tear noted to right elbow. Intervention included neuro checks, nurse practitioner evaluation, therapy evaluation, and to educate the resident to call for assistance when getting out of bed. During an interview on 03/28/24 at 11:23 AM, the Risk Manager was asked if any staff or residents were interviewed related to the recent fall of Resident #13. The Risk Manager provided two written statements, one from the night nurse and one from the CNA. The statement from the night nurse lacked any summary of the occurrence or any documented injury. The statement from the CNA documented the resident stated she was dizzy, which was not a part of the investigation. The Risk Manager explained Resident #13 was alert and oriented, stated she got up on her own to go to the bathroom and fell. The Risk Manager stated she denied hitting her head, although that information was not documented anywhere, that neuro checks were initiated, and the nurse practitioner was notified and examined the resident. When asked if she interviewed either the roommate of Resident #13 or the resident in the connecting room who shared the bathroom, the Risk Manager stated she did not as the resident was alert and was able to say what happened. When told Resident #159 was a witness and even had a photo on her cell phone, the Risk Manager stated she never thought to interview the resident who shared the bathroom. During an interview by the Risk Manager on 03/28/24 at 12:07 PM, Resident #159 showed the photo of Resident #13 lying on the bathroom floor and explained the resident was moaning and stating, Oh my head, Oh my elbow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 19 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure indwelling catheter bags remained off the floor for 3 of 4 sampled residents (Resident #61, #83, and #50); and failed to ensure staff documented the monitoring of input and output of fluids, as per physician orders, for 1 of 4 sampled residents (Resident #50). The findings included: Review of the policy Urinary Catheter Care revised August 2022 documented, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Care: . 4. Be sure the catheter tubing and drainage bag are kept off the floor. 1) Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an indwelling catheter and had an urinary tract infection in the past 30 days. Current orders documented staff were to empty, record and monitor the nephrostomy tubes (urinary catheters placed directly into the kidney) every four hours due to multiple dislodgements due to heaviness. Review of the current care plan initiated on 03/04/24 documented Resident #61 was admitted with bilateral nephrostomy tubes and is at risk for infection. Intervention to this care plan was for staff to monitor the nephrostomy tubes. An observation on 03/26/24 at 2:26 PM revealed the nephrostomy bag for Resident #61 directly on the floor (Photographic Evidence Obtained). During an interview on 03/28/24 at 2:29 PM, the Director of Nursing (DON) was shown the photograph and stated the resident plays with the nephrostomy tube all the time. Review of progress notes and care plans lack any documentation of Resident #61 manipulating the nephrostomy tubes. 2) Review of the record revealed Resident #83 was admitted to the facility on [DATE]. Review of the admission MDS assessment dated [DATE] documented the resident had an indwelling catheter. The current care plan initiated on 02/15/24 and revised on 02/20/24 documented the resident was admitted to the facility with the indwelling urinary catheter and was at risk for urinary tract infections and discomfort. An observation on 03/25/24 at 10:33 AM revealed the urine in the tubing of the urinary catheter was cloudy. A supplement observation on 03/26/24 at 10:33 AM revealed the urinary catheter bag directly on the floor (Photographic Evidence Obtained). On 03/27/24 at 11:20 AM, while sitting up in his wheelchair, the urinary catheter bag was observed hanging from the bottom of the chair, touching the floor. An observation of personal care was made for Resident #83 on 03/27/24 at 5:05 PM with Staff Q, Certified Nursing Assistant (CNA). Upon entering the room, the urinary catheter bag was noted on the floor (Photographic Evidence Obtained). Staff Q proceeded to empty the catheter bag and hook it back onto the bed frame and more of the bag was then on the floor. The CNA raised the bed to provide the care, then lowered the bed upon completion. The catheter bag continued to touch the floor upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 20 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0690 completion of care. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/28/24 at 1:39 PM, when asked about what she looks for regarding the placement of the urinary catheter for Resident #83, Staff L, Registered Nurse (RN) explained how she ensures it is draining and looks for signs and symptoms of infection. When asked if the catheter bag should be on or off the floor, the RN stated it should be off the floor. The RN explained Resident #83 was a fall risk and the bed needed to be low, but also agreed the catheter needed to remain off the floor. Residents Affected - Few During an interview on 03/28/24 at 1:45 PM, the DON was shown the indwelling urinary catheter bag photos of the bag on the floor and agreed they needed to be maintained off the floor. The DON stated they used to use the full vinyl privacy bag, which would protect the bag, but the company developed an all-in-one urinary bag and privacy flap, but agreed that flap did not protect the urinary bag from touching the floor. 3) Resident #50 was admitted to the facility with diagnoses which included Obstructive and Reflux Uropathy and Neuromuscular Dysfunction of Bladder. Resident #50's Quarterly Minimum Data Set assessment, dated 01/16/24, documented resident has presence of an indwelling catheter, and the Resident's Care Plan, completed on 02/01/24 documents that this resident has an indwelling Foley catheter due to a neurogenic bladder, and she is at risk for UTI (urinary tract infection) and discomfort/obstructive uropathy. Interventions in place include monitoring of catheter tubing for kinks, and to make sure tubing is secure, and to monitor intake and output of fluids. Physician orders state to Maintain Foley Catheter to straight drain, keep foley below the level of the bladder, check placement and function every shift, monitor for any kinks in the tubing, keep the urinary drain bag covered every shift. and Document foley catheter output every shift On 03/26/24 at 11:35 AM, Resident #50's catheter bag was observed laying on the floor. On 03/26/24 at 2:57 PM, Resident #50's catheter bag was observed laying on the floor (photo evidence acquired). On 03/28/24 at 10:17 AM, Resident #50's catheter bag was observed with the bottom of the bag touching the floor (photo evidence acquired). A review of March 2024 eMAR shows missing staff initials and documentation signifying Foley output per shift on 03/06/24 for the 11 PM - 7 AM shift and on 03/09/24 for the 7 AM - 3 PM shift. On 03/26/24, 03/27/24 and 03/28/24 during the 7 AM - 3 PM shift, staff documented that the tubing and bag are checked by staff; however, the catheter bag remained on the floor on these dates and times. On 03/28/24 at 1:27 PM, Staff B (LPN) responded when asked what is checked when monitoring the catheter tubing and catheter bag Staff B replied, I check the output and make sure the urine is not cloudy or doesn't contain any blood, I look for signs and symptoms of infection, and if there is a foul smell to the urine. I make sure the tubing is in place and check to make sure the bag is below the level of the bladder to drain properly. There was no mention by Staff B regarding checking to make sure the catheter bag is not laying on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 21 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure proper care and services for a peripheral intravenous (IV) line for 1 of 1 sampled resident (Resident #61). Residents Affected - Few The findings included: Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the current orders lacked any order for an intravenous line, although discontinued orders revealed the resident received an IV medication for three days as of 03/22/24. Review of current care plans lacked any evidence, related to an IV line. During an attempted interview and observation on 03/25/24 at 3:18 PM, Resident #61 was unable to answer any questions. A peripheral IV line was noted to his right forearm dated 03/17/24 (Photographic Evidence Obtained). A supplemental observation on 03/26/24 at 3:37 PM revealed the same IV line dated 03/17/24. The Director of Nursing (DON) was made aware of the peripheral IV line for Resident #61. When asked the process for the peripheral lines, the DON stated they should be changed every three days. During an interview on 03/26/24 at 3:52 PM, when asked if he administered any medications through the IV line of Resident #61 the previous evening, Staff M, Registered Nurse (RN) stated he could not recall. The RN was asked to review the record and determine if the ordered antibiotics were provided on his shift, and the RN confirmed it was and he administered it the previous day. When asked the type of IV line that Resident #61 had, the RN stated he could not recall. When told Resident #61 had a peripheral IV line and asked how often the line should be changed, the RN stated he was not sure. When asked how he would know if an IV line needed to be changed, he stated, If a supervisor or the previous nurse doesn't tell me, it would come up on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 22 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, interview and record review, the facility failed to conduct respiratory assessment with nebulizer treatment per facility policy for 1 of 1 sampled resident reviewed for respiratory concerns (Resident #29) Residents Affected - Few The findings included: Policy review titled, administering medications through a small volume (handheld) nebulizer. Dated October 2010. The policy revealed the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the procedure included: #6. Obtain baseline pulse, respiratory rate and lungs sounds. #15. Instruct the resident to take deep breath, pause briefly and then exhale normally. #26 obtain post-treatment pulse, respiratory rate and lungs sounds. #27 rinse and disinfect the nebulizer equipment according to facility protocol, or wash pieces with warm, soapy water, rinse with hot water. Record review revealed Resident #29 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that blocks airflow and make it difficult to breathe), and Respiratory Failure. The quarterly Minimum Data Set assessment reference date 01/30/23, indicated Resident #29 had a Brief Interview for Mental Status score of 08, indicating he was moderately cognitively impaired. Review of physician orders dated 01/30/23 reads Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale orally via nebulizer every 6 hours for Bronchospasm. Toleration treatment: G-Good; F-Fair; P-Poor; Document # of minutes breathing treatment was administered. Respiratory evaluation: Breath Sound Code: 1=Clear; 2=Diminished; 3=Rhonchi; 4=Crackles; 5=Wheezing; 6=Other (Explain). Quality: A=Unlabored. Review of Care plans with a start revision date of 11/10/23 and completed revision date 11/28/23, indicated Resident #29 had altered respiratory status/difficulty breathing related to COPD, Emphysema, Shortness of Breath, Bronchospasms, Congestive Heart Failure, Acute on Chronic Respiratory Failure, history of Pneumonia, and Covid 19. Interventions included: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Administer medications per physician order. Auscultate lung sounds. On 03/25/24 at 1:35 PM observation of nebulizer administration was conducted with Staff B, a License Nurse Practitioner of Albuterol 0.5-2.5/3ml 1 vial. Staff B retrieved the nebulizer vial, she poured the liquid in the nebulizer cup, subsequently she applied the mask on the resident's face. The nurse did not take the resident's pulse, respiratory rate and she did not listen to the lungs sounds. Staff B voiced that she was going to let the treatment run for 15 minutes. She stated, she was going to set the time on her phone, hence she doesn't forget. Subsequently, Staff B went to the bathroom and washed her hands. She waited in the room with Resident #29 for the entirety of the treatment (total of 16 minutes). Staff B did not attempt to instruct Resident #29 to take deep breaths during the treatment. At 1:51 PM the alarm rang on her phone; Staff B removed the mask and put it away. She did not take the resident's pulse, respiratory rate and lung sounds after the treatment, and did not clean the mask after use. On 03/28/24 at 9:30 AM, an interview was held with the Director of Nursing (DON), she was made aware of the way the nurse conducted the procedure of the nebulizer treatment and she acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 23 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure proper monitoring of blood sugars as evidenced by the failure to notify the physician of blood sugar levels greater than 250, as per physician order, for 1 of 5 sampled residents (Resident #13). Residents Affected - Few The findings included: Review of the record revealed Resident #13 was admitted to the facility on [DATE]. Review of the current orders revealed as of 01/31/24 staff were to obtain and record the blood sugar level for Resident #13 twice daily before breakfast and dinner, and notify the physician if the blood sugar reading was less than 70 or greater than 250, for diabetic monitoring. Review of the March 2024 Medication Administration Record (MAR) and corresponding progress notes revealed the following blood sugar levels that were greater than 250, and the physician was not notified: On 03/01/24 at 4:30 PM the blood sugar reading was 260. On 03/02/24 at 4:30 PM the blood sugar reading was 317. On 03/03/24 at 4:30 PM the blood sugar reading was 346. On 03/14/24 at 4:30 PM the blood sugar reading was 271. On 03/15/24 at 4:30 PM the blood sugar reading was 289. On 03/22/24 at 4:30 PM the blood sugar reading was 267. On 03/23/24 at 4:30 PM the blood sugar reading was 280. Further review of the MAR revealed four of the above readings, the 03/01/24, 03/14/24, 03/15/24, and 03/22/24 dates, were completed by Staff K, Registered Nurse (RN). During an interview on 03/28/24 at 10:49 AM, when asked if she had been notified of any blood sugar levels greater than 250 for Resident #13, Staff N, Advanced Practitioner Registered Nurse (APRN) obtained her cell phone and confirmed she had been notified last evening, 03/27/24 and made changes to the resident's insulin this morning. When asked if she had been notified of any of the other blood sugar readings over 250, the APRN reviewed one or two of her progress notes and stated she had not. During an interview on 03/28/24 at about 3:15 PM, Staff K, RN, was asked about the blood sugar levels for Resident #13. The RN volunteered that she would call the physician if the reading was greater than 300, as that was the facility standard. When shown the order to call the physician if greater than 250, the RN stated Oh, and agreed she had not done so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 24 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to honor resident's food preference for 1 of 10 sampled residents reviewed for food concerns (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. On 03/25/24 at 10:20 AM, Resident #25 stated that all he gets for breakfast is sausage, sausage, sausage! He stated he would really like some bacon and ham sometimes, not always sausage. On 03/25/24 at approximately 11:30 AM, the Registered Dietitian was informed of Resident #25's request for more variety in choice of breakfast meats. She stated she would speak with the Resident to try to accommodate his request. A review of a Dietary Note dated 03/25/24 at 1:33 PM documents: Met with resident. He is requesting bacon at breakfast time. Explained bacon in relation to therapeutic diet and diet consistency. Resident verbalized understanding and requested to receive bacon despite its contra-indication for diet order. SLP [Speech Language Pathologist] evaluated for safety. Will continue to monitor and implement nutrition care. Proceed to CP [Care Plan]. A review of Resident #25's Renal/CKD [Chronic Kidney Disease] dialysis diet Order dated 02/27/24 documents, Mechanically Altered Chopped texture, Thin Liquids consistency, May have bacon at breakfast, upon request. On 03/27/24 at 12:25 PM, Resident #25 stated, I got sausage again this morning. I have told staff and speech therapist that I wanted something other than sausage, and I still get sausage. I would really like some bacon. On 03/28/24 at 12:10 PM, Resident confirmed that, once again, he received sausage that morning for breakfast. When I saw the sausage, I put the cover back on my plate, and refused to eat it. I sent it back! I don't know why I can't get something besides sausage every morning! FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 25 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to store, prepare and serve foods in a sanitary manner, in accordance with professional standards for food safety. The findings included: 1). During the initial kitchen tour, on 03/25/24 at 8:44 AM, accompanied by the Dietary Manager, the following were noted. a. The blade of the can opener was noted to have food residue and the surface of the blade was peeling. b. Staff were observed using a damp cloth to wipe the lid of Cambro containers. c. There was an accumulation of ice on the cooling unit and on top of boxes of products that were stored directly under the cooling unit in the walk in freezer. d. The handles of knives were damaged to a point that made them uncleanable non-food contact surfaces. e. Raw shell eggs were stored over pasteurized shell eggs in walk-in refridgerator. f. Staff H, Dietary Aide, was observed rinsing towels in the only hand washing sink in the food service area and leaving food residue in the basin. g. Staff I, Cook, was observed wrapping pork chops in foil and placing them in an ice bath. Staff I stated that he needed to cool the pork chops in order to process them for mechanically altered (mechanical soft, ground and puree) for the lunch meal on this day. Staff I stated that wrapping the product in foil and covering it with ice was the facility's procedure for rapidly cooling food. 2a). On 03/25/24 at 10:55 AM, the Surveyor returned to the kitchen to further observe the cooling and reheating process for the mechanically altered pork chops. Upon arriving to the kitchen, the pork had already been processed to mechanically altered and placed on the steam table. At the time of the observation, Staff I stated that the mechanical soft pork chops, ground pork chops and puree pork chops had been in the hot holding unit for approximately 20 minutes. The internal temperature of the mechanical soft pork was 119 degrees Fahrenheit (F), the internal temperature of the ground pork was 121 degrees F, and the internal temperature of the puree pork was 117 degrees F. All temperatures were taken using the facility's calibrated metal stemmed probe-style thermometer. b. While taking the internal temperatures of the pork products on the hot holding unit, Staff I was observed disinfecting the probe of the thermometer with an alcohol swab. It was noted that Staff I did not disinfect the [NAME] of the thermometer (the non-food contact part of the probe and thermometer) and inserted the probe directly into the pork products up to the [NAME] of the thermometer. c. The thermometer of the mechanical ware washing machine showed that the temperature of the water during the wash cycle, rinse cycle and sanitizing cycle reached was 110 degrees F and did not reach (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 26 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave 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 Level of Harm - Minimal harm or potential for actual harm the 120 degrees F that was necessary for the machine to properly wash, rinse and sanitize. The temperature of the water in the basin was measured using the facility's calibrated metal stemmed probe-style thermometer and found to be at the appropriate temperature. d. There was dirty ice in the only hand sink in the food service area. Residents Affected - Some 3). During an interview, on 03/25/24 at 2:58 PM, with the Registered Dietitian and the Dietary Manager, when asked about Staff I following proper cooling and reheating techniques for preparing the mechanically altered pork, the Registered Dietitian and the Dietary Manager were unable to confirm if Staff I followed proper cooling and reheating techniques by use of a thermometer to monitor the temperatures during the process. During the interview, the Registered Dietitian acknowledged that the recipe and the facility's policy only documented the parameters for proper cooling and reheating of potentially hazardous foods and did not document techniques for meeting the parameters. 4). During a follow up tour of the kitchen, on 03/27/24 at 11:25 AM, accompanied by the Registered Dietitian and the Dietary Manager, Staff J, Dietary Aide, was observed removing lids from the foods on the hot holding unit and placing the lids on a shelf directly on top of clean, sanitized and dry pans, lids. 5). On 03/28/24 at approximately 2:00 PM, the basin of the only hand sink in the food services area was full of ice. The Dietary Manager was made aware of the observation and multiple observations of the sink having used ice in it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105555 If continuation sheet Page 27 of 27

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Citations

15 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0565GeneralS&S Epotential for harm
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
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.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0585GeneralS&S Epotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
0354GeneralS&S Dpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

FAQ · About this visit

Common questions about this visit

What happened during the March 28, 2024 survey of JUPITER REHABILITATION AND HEALTHCARE CENTER?

This was a inspection survey of JUPITER REHABILITATION AND HEALTHCARE CENTER on March 28, 2024. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at JUPITER REHABILITATION AND HEALTHCARE CENTER on March 28, 2024?

Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 1, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 28, 2024