Health inspection·January 28, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the nursing staff failed to follow prescribed parameters including blood sugar and blood pressure results for 2 of 4 sampled residents (Resident #1 and Resident #5). Residents Affected - Few The findings included: 1) Clinical record review revealed Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes. The Minimum Data Set assessment with reference date of 12/27/24 revealed the resident was assessed as moderately impaired for skills of daily decision making and is receiving insulin and hypoglycemic medications. A review of a Care plan dated 12/21/24, documented Resident #5 has Diabetes Mellitus with Hyperglycemia. The interventions included: Diabetes medication as ordered by doctor and monitor and document for side effects and effectiveness. Review of Physician's order dated 01/23/25, documented Insulin Lispro subcutaneous solution pen injector, 100 units per milliliter, Inject 2 units subcutaneously before meals for Hyperglycemia. Hold for glucose less than 150. Review of the Medication Administration Record dated 01/2025 documents Resident #5 received the Lispro insulin on the following dates, despite documented blood sugar below 150. On 01/23/25 the evening dose was given with blood sugar reading of 110. On 01/24/25 the evening dose was given with blood sugar reading of 110. On 01/25/25 the evening dose was given with blood sugar reading of 123. On 01/26/25 the evening dose was given with blood sugar reading of 119. 2) Clinical record review conducted on 01/27/25 revealed Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Congestive Heart Failure and Hypertension. The Minimum Data Set assessment with reference date of 12/27/24 revealed the resident was assessed as independent for skills of daily decision making and is receiving diuretic medications. Page 1 of 2 105555 105555 01/28/2025 Jupiter Rehabilitation and Healthcare Center 17781 Thelma Ave Jupiter, FL 33458

F 0684 Review of a Care plan dated 08/01/24 documented interventions as administer medications as ordered. Level of Harm - Minimal harm or potential for actual harm Review of Physician's order dated 12/20/24 documented Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day for Hypertension, hold for systolic blood pressure less than 110. Residents Affected - Few Review of the Medication Administration Record dated 01/2025 documents the medication was given on 01/17/25 with a documented blood pressure of 106/60 and on 01/26/25 given with a blood pressure of 92/58. Interview with the Director of Nursing on 01/28/25 at 3:14 PM confirmed the medications were given despite the prescribed parameters. 105555 Page 2 of 2