Health inspection·March 6, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and clinical record review, the facility failed to ensure that residents who are unable to carry out their activities of daily living to maintain personal hygiene, grooming, mobility are provided the necessary care and services in a timely manner. The facility also failed to maintain accurate documentation of the care and services that are provided. This failure affected 3 of 6 sampled residents (Resident #1, #5 and a confidential random resident). Residents Affected - Few The findings included: 1) Review of the clinical record for Resident #5 revealed that the resident was admitted to the facility on [DATE] with diagnoses which included, Dysphasia following Cerebral Infarction, Pneumonitis following ingestion of other solids and liquids, Acute Respiratory Failure, Sepsis, Cardiac Arrest due to other underlying conditions, Gastrostomy, Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Metabolic Encephalopathy. Review of the 03/04/25 plan of care revealed that the resident takes nothing by mouth and receives enteral feeding. It is noted that the resident is dependent for the performance of his activities of daily living including bathing, bed mobility, transfers and is incontinent of bowel and bladder. An observation of Resident # 5, conducted on 03/06/25 at approximately 2:15 PM revealed that the resident was lying in bed with the top sheet removed, exposing his adult incontinent brief, which was obviously wet. The surveyor summoned the aide, Staff E, at this time. An interview was conducted with Staff E, who admitted that the last time she provided care for Resident #5 was about 10:30 AM this morning, approximately 4 hours ago. 2) A review of the Paramedic Trip records dated 02/25/25 at 10:59 AM for Resident #1, documented, upon arrival the crew found the patient (pt), unresponsive and lying in bed. The pt had a CPAP (Continuous Positive Airway Pressure) machine on his face with normal respirations, a strong radial pulse with cool extremities. The pt has old urine soiling his clothing and his bed sheets. The PA (Physician Assistant) on scene advised that the pt is being treated for the flu and a UTI (Urinary Tract Infection), he is on multiple antibiotics and steroids. They advised that the pt is normally alert and talking with no deficits. The facility is unable to tell the crew how long the pt has been unresponsive. The clinical record for Resident #1 revealed that the resident was admitted to the facility on [DATE] with diagnoses which included, Obstructive Sleep Apnea, Shortness of Breath, Chronic Kidney Disease, Stage 4, Diabetes Mellitus Type 2 with circulatory complications, and Influenza. Page 1 of 2 106148 106148 03/06/2025 Luxe at Jupiter Rehabilitation Center (the) 674 Pioneer Road Jupiter, FL 33458

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Day Registered Nurse, Staff B, on 03/05/25 at 3:20 PM. She works from 7:00 AM to 7:00 PM. She stated that [on 02/25/25] she saw the resident around 7:45 AM-8:00 AM and he was sleeping with his CPAP. She stated she received report that the resident was okay, and that the resident was sleeping with his CPAP. No distress. She stated she went in to try to wake him and he would not wake up. His vital signs were ok, and she said she checked his blood sugar earlier and it was 140. She said she does recall the resident's bed sheet being wet the last hour before he was sent out, but she didn't recall any discoloration being on the sheet. An interview was conducted with the Day Certified Nursing Assistant, Staff D, on 03/05/25 at 3:30 PM. She stated when she made rounds at 7:00-7:30 AM, the resident was sleeping with his CPAP on. When breakfast arrived, they noted that he didn't respond. She reported she changed the resident before and after breakfast. She stated she changed the residents' pull up not the sheets. She didn't recall that the residents' sheets were wet. She reported the resident had on a shirt and diaper. She denied that she changed the linen, she just changed the resident. Review of the Activities of Daily Living Task sheet revealed that the staff failed to document the performance of any activities of daily living for Resident #1 on 02/24/25 and 02/25/25. Review of Resident #1's Plan of Care, it documented the resident is at risk for complications r/t (related to) bowel and/or bladder incontinence with interventions which included: Monitor/observe for potential complications of incontinence. Notify MD as indicated. Monitor/report PRN (as needed) any possible causes of incontinence including, but not limited to, bladder infection, constipation, loss of bladder tone, muscle weakness, decreased bladder capacity, diabetes, Stroke, medication side effects. Preventative skin care/treatments as ordered/indicated. Provide incontinence care with each incontinence episode as tolerated. Urinal within reach. Review of Resident #1's Plan of Care documented the resident has an potential for ADL selfcare deficit r/t ADL needs and participation vary, Fatigue, chronic medical conditions. Flu A with respiratory infection. The interventions included: Toileting: the resident will need the extensive help of one or two staff to stand and transfer on and off the toilet, commode or bed pan. The resident will probably need you to wipe, redress, and wash their hands. Be prepared with 2 people to assist for resident safety during the transfer. Transfer: the resident is limited to extensive and may need assistance x 1 or x 2 for transfers in and out of chair or bed. This may fluctuate with weakness, fatigue, and weight bearing status. 3) A confidential random resident interview was conducted on 03/06/25 in the afternoon, when the resident reported that he has issues with the night shift staff providing care. He recalled a couple of nights ago, that he put on his call light because he was incontinent. They answered the light and stated they would be back, but they did not come back to change him until 4 hours later. 106148 Page 2 of 2