Inspection·December 9, 2025

F0000 INITIAL COMMENTS F0000 /2026 An unannounced complaint survey, for complaint numbers 2025017714 (cited F755), 2025017299, and 2025017088 at Luxe at Wellington Rehabilitation Center (The) was conducted on . The facility was not in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

F0755 SS = D Pharmacy Svcs/Procedures/Pharmacist/Records F0755 /2026 CFR(s): 483.45(a)(b)(1)-3) $483.45(a) Services. The facility must provide routine and emergency drugs and biologicals to its residents, and obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. $483.45(a) Procedures. A facility must provide pharmaceutical services (including services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. $483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- $483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. $483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and $483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is TAG#F0755 Description: Pharmacy Services/Procedures/Pharmacist/Records IMMEDIATE CORRECTIVE ACTION: 1. Resident # 4 experienced no adverse outcome related to the alleged deficient practice. The resident remained on hospice care in the facility until , at which time he expired. Staff A was counseled by the Director of Nursing on ensuring that residents do not share medications, medications are ordered timely, that medications cannot be borrowed and ensuring she gives medication as ordered by physician. The Med Pass policy was reviewed with the Nurse. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: All residents in the facility receiving medications have the potential to be affected by the alleged deficient practice. A facility wide comprehensive review was completed to confirm that all residents had the medications available as ordered there were no outstanding 106091 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0755 SS = D Continued from page 1 maintained and periodically reconciled. This REQUIREMENT is NOT MET as evidenced by: Based on observation, record review and interviews, the facility failed to ensure standards of practice for administration of medication for 1 of 3 sampled residents, as evidenced by failure to ensure Resident #4 received medication as prescribed and ensure medications were refilled in a timely manner. The findings included: Record review revealed Resident #4 was admitted to the facility on documented a history of Review of medical diagnosis with ( with , on one side). During an observation of medication administration on at 9:56 AM Staff A, Licensed Practical Nurse prepared Eldertonic (appetite supplement) 15milliliters (ml), 500mg (1 tablet) (1 tablet), Pantopazole ( 40 mg (1 tablet), (increase ammonia level) 15grams/15ml (30ml), cup. After pouring 30 milliliters in a medicine cup, Staff A handed the surveyor the medicine bottle and stated "He is out of this medication. It had to be reordered." Observation revealed the medicine bottle had a prescription label on it with a different resident's name. After preparing the medication Staff A went into the resident's room and administered the 2 pills which had been crushed in apple sauce, 15ml Eldertonic and 30ml of evidence obtained. (photographic During an interview on at 10:18 AM, when she was asked when the for Resident #4 was reordered, Staff A stated "Today" (as she looked in the computer) When asked when the medication was reordered prior to today, she stated, "On She was asked how much the resident and she said 30ml. Staff A was administered to the surveyor on the computer to verify the order and after doing so, she stated "It says15ml. Well, it was 30ml they must have changed the order." Review of a physician orders for Resident #4, dated instructed staff to administer , Oral Solution 10 GM/15ML ( ( for . , ) Give 15 ml by two times a day

F0755 Continued from page 1 medication orders and that all medication were delivered as scheduled. This review was completed by the Assistant Director of Nursing and the Unit Manager on . No issues were identified. SYSTEMATIC CHANGES: The Assistant Director of Nursing conducted ongoing In-services with nursing staff on facility practices as it relates to med-pass and documentation of Medication administration pass and physicians' orders. The pharmacy Consultant/DON designee conducted medication pass competencies with active licensed nurses to ensure competency. Newly hired nursing staff will be educated during orientation on Med-Pass and documentation of medication administration according to physician's orders. MONITORING: Quality Review Tools will be utilized by the Unit Manager/designee daily times 14 days to support compliance. A minimum of 15 patients on each unit will be reviewed. Additionally Quality Reviews are to be conducted by regional Director of clinical services/designee daily times 14 days to support compliance. A minimum of 15 patients on each unit. The Director of Nursing/Designee will report issues or concerns identified and corrected by the DON/designee to the Quality Assurance Performance Improvement Committee monthly for 3 months to ensure substantial compliance is achieved and maintained. Florida Department of Health LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0000 INITIAL COMMENTS N0000

N0090 SS = D Pharmacy Policies and Procedures N0090 /2026 CFR(s): 59A-4.112(1), FAC (1) The nursing home licensee must adopt procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologics, to meet the needs of each resident. This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on observation, record review and interviews, the facility failed to ensure standards of practice for administration of medication for 1 of 3 sampled residents, as evidenced by failure to ensure Resident #4 received medication as prescribed and ensure they are refilled in a timely manner. The findings included: Record review revealed Resident #4 was admitted to the facility on . Review of medical diagnosis documented a history of with . ( with , on one side). During an observation of medication administration on at 9:56 AM Staff A, Licensed Practical Nurse prepared Eldertonic (appetite supplement) 15milliliters (ml), ) 500mg (1 tablet) , Pantopazole ( ) 40 mg (1 tablet), and (increase ammonia level) 15grams/15ml (30ml). After pouring 30 milliliters of in a medicine cup, Staff A handed the surveyor the medicine bottle and stated "He is out of this medication. It had to be reordered." Observation revealed the medicine bottle had a prescription label on it with a different Office of Primary Care and Health Systems Management Florida Department of Health LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

N0090 SS = D Continued from page 1 resident's name: "After preparing the medication Staff A went into the resident's room and administered the 2 pills which had been crushed in apple sauce, 15ml Eldertonic and 30ml of evidence obtained. (photographic During an interview on at 10:18 AM, when she was asked when the for Resident #4 was reordered, Staff A stated "Today" (as she looked in the computer) When asked when the medication was reordered prior to today, she stated, "On She was asked how much she stated, "On she administered to the resident and she said 30ml. Staff A was asked by the surveyor to look in the computer to verify the order and after doing so, she stated "It says 15ml. Well, it was 30ml they must have changed the order." Review of a physician orders for Resident #4, dated instructed staff to administer Oral Solution 10 GM/15ML ( ( , ) Give 15 ml by two times a day Class III STATE FORM