Inspection·March 12, 2026

F0000 INITIAL COMMENTS

F0000 /2026 An unannounced Recertification and Complaint survey, complaint #2025019422 and #2026002348, was conducted on at Luxe at Wellington Rehabilitation Center. The facility is not in compliance with 42 CFR Part 483. Requirements for Long Term Care Facilities. Complaint #2026002348 was substantiated with a deficiency cited at F684 and complaint #2025019422 was not substantiated.

F0058 SS = D Reasonable Accommodations Needs/Preferences

F0058 Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the prepared and/or executed solely because it is required by provisions of the Federal and State laws. /2026 CFR(s): 483.10(e)(3) $483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. TAG#F0058 Description: Reasonable Accommodations Needs/Preferences This REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview and record review, the facility failed to provide accommodation of needs to 1 of 1 sampled resident as evidenced by the air mattress not providing proper support and ensuring the call light was functional for Resident #11. IMMEDIATE CORRECTIVE ACTION: 1. Resident #11 assessed by RN on duty on and experienced no adverse outcome related to the alleged deficient practice. The air mattress was immediately replaced by the maintenance staff on and call light was repaired on when identified. The findings included: Review of the facility policy titled, "Equipment Maintenance" with no date listed under revision date, documented in part, Responsibilities-Staff. Reports equipment immediately and removes the unsafe items from service. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Review of the record revealed Resident #11 was admitted to the facility on with diagnoses including Low and Lymphedema. Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a ( ) score of 14, on a 0 to 15 scale, indicating intact cognition. All residents in the facility using call light and an air mattress have the potential to be affected by the alleged deficient practice. 2.A facility wide comprehensive review was completed on by the Care Nurse and Maintenance Director for all residents using an air mattress to ensure they are in working order and providing proper support. No issues were identified. The assessment documented that Resident #11 had skin conditions and risk of, Review of 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

F0558 SS = D Continued from page 1 Physician Orders for Resident #11 dated documented, Low Air Loss Mattress: Check pressure and function every shift. An initial interview was conducted on AM with Resident #11 who stated that her call light was broken. She further explained that she was having a problem with her bed; the air mattress was not working, and it felt like she was sitting on bones. At that time, Staff F, Licensed Practical Nurse (LPN) came in to check on Resident #11. The resident informed Staff F that her call light and the air in her mattress was not working. Staff F checked the call light and agreed that it was not working and stated that she would go call for Maintenance. An interview was conducted on Resident #11 stated that her call light had been replaced but they still had not fixed the air in the bed. at 9:01 AM, and On at 9:11 AM, Staff F and Staff D, Certified Nursing Assistants (CNA) came in to assist with repositioning Resident #11 in her bed and were advised that the resident felt like the air in her bed was not working in the air mattress. Staff F checked the mattress under Resident #11’s area and agreed that the mattress felt sunken and stated that she had talked to someone from Maintenance on and mattress. Staff F stated that they did fix the call light, but they may not have fixed the mattress. On at 10:47 AM, Staff F was asked if she had contacted maintenance and replied that someone had contacted Maintenance for her and that she would go downstairs to get them. An interview was conducted on Staff F, Maintenance Assistant who has worked in the facility for one year. Staff F was asked if he had fixed the call light for Resident #11 on and he stated that he did fix the call light but was not told about the mattress issue. He was able to show on the TELS system where the work orders had been placed for Resident #11 to address her air mattress on and. Staff F stated that he had assessed the air machine for low pressure and replaced the machine and mattress during previous reports of issues with Resident #11’s mattress. A work order entered on , after surveyor intervention.

F0558 Continued from page 1 A facility wide comprehensive review was completed on by the Maintenance Director for all residents call lights to ensure they are in working order. No issues were identified SYSTEMATIC CHANGES: 3. The Assistant Director of Nursing/Maintenance Director conducted ongoing in-services with current staff and new hire on facility practices as it relates component of F0558 with emphasis on ensuring Staff reports , equipment, immediately and removes the unsafe items from service. Maintenance Director/NHA will review reports of , equipment at daily morning meeting 5 x weekly to ensure timely follow up and resolution. MONITORING: 4. Quality Review Tools will be utilized by the Care Nurse /designee weekly x 4 for residents using an air mattress, then twice a month x 2 months to support compliance. Quality Review Tools will be utilized by the Maintenance Director /designee weekly x 4 then twice monthly x two months to randomly check residents call lights on all units to support compliance. The Assistant Director of Nursing/Corrective to the Quality Assurance Performance Improvement Committee monthly for 3 months to ensure substantial compliance is achieved and maintained.

F0561 SS = D Self-Determination CFR(s): 483.10(f)(1)-(3)(8)

F0561 IMMEDIATE CORRECTIVE ACTION: /2026 LUXE AT WELLINGTON REHABILITATION CENTER THE | 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 --- | --- | --- | --- | ---

F0561 | Continued from page 2 | F0561 | Continued from page 2 | SS = D | $483.10(f) Self-determination. | | 1.Resident #129 was addressed and received a shower on by nursing staff assigned for care. Resident preference was updated and is being followed by staff. | | The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. | | IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Residents that has a preference for showers have the potential to be affected by the alleged deficient practice | | $483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plans of care and other applicable provisions of this part. | | 2. DON/ADON completed a comprehensive audit on for residents to ensure that resident's shower preference was identified and plan of care updated to reflect resident's Shower preference. | | $483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. | | SYSTEMATIC CHANGES: | | $483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. | | 3. On licensed nurses and CNAs were re-educated by DON/ADON on the components of F0561 with emphasis on ensuring that resident's shower preference and scheduled and informing nurses of refusals to ensure care plan is updated to reflect changes/refusals. | | $483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. | | Newly admitted residents will be offered a choice of shower and/or bath with a schedule as preferred. | | This REQUIREMENT IS NOT MET as evidenced by: | | Preferences and refusal of care will be reviewed at daily morning meeting 5x weekly to ensure ongoing follow up and resolution. | | Based on record review and interviews, the facility failed to honor the shower preference and schedule for 1 of 4 sampled residents reviewed for choices for (Resident#129). | | MONITORING: | | The findings include:Review of the electronic record for Resident #129 revealed he was admitted to the facility on . Record review revealed the resident's Care Plan documented the following for ADLs (Activities of Daily Living): Resident has an ADL self-care related to a diagnosis of Cholelithiasis ADL needs and participation varies over the course of the day/week, generalized balance, Limited Mobility. The interventions included Encourage and assist with all ADL tasks as indicated and as tolerated by resident and based on resident's strengths; Encourage resident to do as many ADL tasks for themselves as possible, ADL Care: the resident may need assistance; CNA (Certified | | 4. Director of Nursing/ADON will complete random daily quality review audits of residents' shower preferences to ensure it is honored for two (2) weeks on all units, then weekly for two (2) months to ensure ongoing compliance. Findings will be reported to the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. | 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 CROSS-REFERENCED TO THE DATE

F0561 SS = D Continued from page 3 Nursing Assistants) Bathing: The resident needs assist of based on fatigue. Further review of her record documented her shower/bathe schedule were Monday, Wednesday and Friday. Her task sheet that documents the shower/bathe schedule documented a "yes" next to There was also a refusal documented on a shower or bath. The task sheet does not document if this was a sponge bath. A review of a task sheet titled, bath revealed the dates There were no check marks under the word "showers." Under the word "sponge bath", there was documentation indicating the resident had one on 02/28 and 02/29, the schedule documented the resident had a full body bath. During an interview on at 9:10 AM, Resident #129 resident was alert and oriented and able to respond to all questions asked. She stated that she has never had a shower and wants one. She expressed that she really wants her hair washed. She stated that the full sponge bath she had, she did herself. During an interview on at 9:24 PM with the Regional MDS (Minimum Data Set) Coordinator, she reviewed the shower book and could not find any documentation of showers for Resident #129. She then went into the resident's room and the resident advised her, she wants a shower after lunch. During an interview on at 9:45 AM with Staff J, Certified Nursing Assistant, she was asked about Resident #129's shower schedule. Staff J stated that she hasn't asked her (Resident #129), but she hasn't asked for one. F0561

F0677 SS = D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2) $483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT IS NOT MET as evidenced by: Based on policy review, observation, record review, and interview, the facility failed to ensure care for 2 of 5 sampled residents reviewed for Activities of Daily Living, as evidenced by the failure to trim and clean the of Resident #1 and Resident #21. F0677 IMMEDIATE CORRECTIVE ACTION: /2026 1. Resident #1, and resident #21 were cut and trimmed on by nursing staff assigned for care. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: 2. DON/ADON completed a comprehensive audit on for residents' , and any identified residents with long were cut and trimmed per resident's preference. LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

F0677 SS = D Continued from page 4 The findings included: Review of the facility policy titled, "Activities of Daily Living (ADLs), Supporting...reviewed, documented in part, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene." 1) Review of the record revealed Resident #1 was admitted to the facility on . Review of the current Minimum Data Set (MDS) assessment dated documented a [ ] score 14, on a 0 to 15 scale, indicating the resident was This same MDS also documented the resident needed partial to from staff for personal hygiene. Review of the current care plan initiated on and revised on documented the resident had an ADL self-care related to fatigue and , medical conditions. This care plan documented the resident needs limited to from staff for all ADL care. During an interview and observation on at 12:08 PM, Resident #1 was observed with excessively long , with the nail extending nearly a quarter inch past the ends of the . When asked if he preferred his nails at that length, the resident stated he did not and wanted them clipped. When asked if staff had offered to assist with his nail care, the resident stated they had not. During a supplemental observation on PM, the resident's remained elongated. During an interview on at 4:16 PM, when asked who was responsible for cleaning and trimming the resident's , Staff B, Licensed Practical Nurse (LPN)/ First Floor Unit Manager stated the CNAs (Certified Nursing Assistants) should be cleaning and filing with morning care for their residents. The Unit Manager observed the resident's and agreed with the findings. 2) Record review revealed Resident #21 was admitted to the facility on . Her diagnoses included: ( ), , and without residual Need for Assistance with Personal Care. Per the Minimum Data Set (MDS) assessment dated F0677 Continued from page 4 SYSTEMATIC CHANGES: 3. On licensed nurses and CNAs were re-educated by DON/ADON on the components of providing care to residents and informing nurses of refusals to ensure care plan is updated to reflect changes/refusals. Preferences and refusal of care will be reviewed at daily morning meeting 5x weekly to ensure ongoing follow up and resolution. MONITORING: 4. Director of Nursing/ADON will complete weekly quality review audits of residents' care for four (4) weeks, then monthly for two (2) months to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 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

F0677 SS = D Continued from page 5 , this resident's ( , ) score equaled 01. This indicated that Resident #21 had severe . The Minimum Data Set (MDS) assessment dated showed that Resident #21 required maximal assistance with the ADL to clean herself. An intervention listed in Resident #21's Care Plan for ADL self-care dated , was to keep the resident clean, dry, and well-groomed. An observation of Resident #21 in her room on at 5:30 PM revealed her were long. There was dark brown-black matter beneath her . Some of the extended one quarter to one half of an inch past the . Photographic Evidence Obtained. During an interview with Resident #21 on preferred her at 5:30 PM it was revealed that she to be shorter. An observation of Resident #21 in her room on at 1:30 PM revealed that her were long. There was dark brown-black matter beneath her . Resident #21 stuck her left- in the ground meat with gravy that was on her meal plate. Her left- had more brown-black matter than the on her right . Photographic Evidence Obtained. An interview on at 5:25 PM was conducted with Staff A, CNA, who provided care to Resident #21. When Staff A was asked to describe Resident #21's , she said that they were of medium length. She asked Resident #21 if she would allow her to cut and clean her nails after she finished eating dinner. Resident #21 nodded her in agreement and said yes. An observation on Resident #21's at 9:20 AM revealed that were short and clean.

F0684 SS = D Quality of Care CFR(s): 483.25 $ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

F0684 IMMEDIATE CORRECTIVE ACTION: /2026 1. Resident # 4, #116, were assessed by RN on duty and experienced no adverse outcome related to the alleged deficient practice. Resident #127 was discharged on from facility. Staff K and Staff H received a one-to-one education from the ADON regarding coordinating care with consultant physician with emphasis on ensuring medications are administered as ordered. 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

F0684 SS = D Continued from page 6 This REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview, and record review, the facility failed to ensure appropriate and timely care and services for 3 of 24 sampled residents as evidenced by the failure to coordinate care with a consultant physician to ensure continued administration for Resident #4, failure to ensure care for a to the left lower extremity of Resident #116, and failure to ensure documented readings at the time of administration of an ) medication with physician ordered parameters for Resident #116; and failure to follow physician ordered parameters for medications for Resident #127. The findings included: 1) Review of the record revealed Resident #4 was admitted to the facility with the current Minimum Data Set (MDS) assessment dated documented the resident was ( ) score of 15, on a 0 to 15 scale, indicating the resident was This same MDS documented the resident was on an ( ) medication. Review of the current physician order revealed as of Resident #4 was to receive (an ... ) via once daily until Previous physician orders revealed the resident received the ... from through The record lacked any evidence of administration or reason for the lack of administration on ... and A progress note dated ... confirmed Resident #4 went to the (ID) physician that day. A physician's order from the ID physician dated documented the resident was to continue the ... until During an interview on ... at 11:35 AM, Resident #4 explained she had gone to the ID physician last Tuesday ( ), had received written orders to extend for two weeks. Resident #4 stated she took a photo of the order and handed it to the nurse upon return from the consultant physician's office. Resident #4 stated by Friday morning ( ), she was not getting the ... The resident stated she spoke with a supervisor on that Friday and told her the issue. The supervisor responded she would take care of it, but never heard from her or

F0684 Continued from page 6 IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: 2. DON/ADON completed a comprehensive audit on for residents on ... medications with parameters and with ... to ensure physicians orders are carried out as ordered and that resident with have follow up orders to ensure care is provided. SYSTEMATIC CHANGES: 3. On ... licensed nurses were re-educated by DON/ADON on the components of F0684 with Emphasis on ensuring physician orders are carried out accurately and timely for Residents on ... medications with parameters and that Residents with ... has follow up orders to ensure care is provided. The Director of Nursing will review all new orders with clinical team at daily morning meeting to ensure accuracy in documentation and that timely follow-up care is carried out. MONITORING: 4. Director of Nursing/ADON will complete quality review audits of residents' EMAR and ETAR to ensure physician orders are carried out accurately and timely for Medications. - Hypertensive medications with parameters, and that ... have follow up orders to address, daily x 2 weeks, weekly x 8 weeks to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 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

F0684 SS = D Continued from page 7 anyone else again. Resident #4 stated she went through the weekend and Monday without the for her Resistant Staph ( that was difficult to treat), of her left and they finally got the restarted Monday evening. During an interview on at 10:43 AM, when asked about the process for new orders when a resident goes out to a consultant physician, Staff B, Licensed Practical Nurse (LPN)/Unit Manager, explained when the resident returns from the , they give the new order to a nurse. The Unit Manager stated if the resident order is to continue the, the nurse is to ask the residents if they received one, and if not, they are to document the lack of an order in the medical record. When asked what happened to Resident #4's through on , the Unit Manager stated she was unaware of any issue. When told of the consultant's physician order to continue the and that it did not get put into place upon return from the office visit, the Unit Manager had no explanation but agreed with the findings. 2) Review of the record revealed Resident #116 was admitted to the facility on . Review of the initial nursing assessment from skin issues to the resident's left . Review of the weekly skin assessment documented the resident had a having sustained a on that same day. The weekly skin checks for and lacked any mention of the Review of physician orders lacked any order for care to the resident's left . During an observation and interview on at 10:01 AM, a large (approximately 4 inches by 6 inches) white that was curled up along the edges and had a faded date of was noted to the resident's left . Upon observation along the edge a bloody-like area about 2 inches in diameter was seen through the . When asked how long the resident stated, "about a week or so." Photographic evidence obtained. During the medication pass observation with Staff K, Registered Nurse (RN), on at 9:45 AM, the same was noted to the resident's left . During an observation on at 4:09 PM, the same remained on the resident's left .

F0684 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

F0684 SS = D

F0684 Continued from page 8 When shown to Staff B, LPN/Unit Manager, she agreed with the findings. 3) Review of the record revealed Resident #116 was admitted to the facility on with diagnosis to include essential .. Review of the physician orders revealed as of Resident #116 was to receive the medication 50 mg (milligrams) twice daily at 9 AM and 5 PM, but to hold the medication for a less than 100 (the top number of the reading) of the corresponding Medication Administration Record (MAR) for lacked any documented or rate readings with the medication. During a medication pass observation for Resident #116 on at 9:19 AM, Staff K, Registered Nurse (RN) held the resident's reading was because the documented a Review of the MAR reading of not taken at the time of the medication pass , clearly observation. Further review of the MAR documented daily vital sign reading for the day shift (7 AM to 7 PM) and the night shift (7 PM to 7 AM). This entry lacked any specific time for the vitals, thus there was no way to know if the and rates were taken with the medication. This documentation also lacked two entries on the day shift to incorporate both doses of medications on that shift. Review of the vital sign summary documentation lacked any vitals at 5 PM for 9 of 11 days. During a side-by-side review of the record and interview on at 10:43 AM, Staff B, Unit Manager, agreed with the lack of documented and rates. 4) Review of the electronic records for Resident #127 revealed that he was admitted to the facility on with a readmission from the hospital on and . His diagnosis included Diastolic Major . { ). Generalized and of the or .. Further review of the physician's order revealed he had an order for Release 24 Hour 25 MG, to give 1 tablet by two 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

F0684 SS = D Continued from page 9 Hold for times a day for , less than 100 or Diastolic (DBP) less than 60 or rate ( .The start date was and the end date Further review of this medication on the Medication Administration (MAR) revealed the following dates this medication was given and should have been held per the physician parameters. On the 09:00 AM dose of , the was .The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 09:00 AM dose of , the was .The diastolic of 53 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 05:00 PM dose of , the was .The diastolic of 52 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 09:00 AM dose of , the was .The diastolic of 54 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 05:00 PM dose of , the was .The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 09:00 AM dose of , the was .The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 05:00 PM dose of , the was .The diastolic of 51 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On the 09:00 AM dose of , the was .The diastolic of 50 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. During an interview on at 10:15 AM with the Director of Nursing (DON), he reviewed the MAR (Medication Administration Record) for and acknowledged the findings. DATE

F0684 SS = D Continued from page 10 During an interview on at 1:02 PM Staff H, LPN (Licensed Practical Nurse) She reviewed the MAR for and stated she would not give it but acknowledged she had a check mark next to the resident's name and gave it when she shouldn't have. F0684

F0685 SS = D Treatment/Devices to Maintain Hearing/Vision CFR(s): 483.25(a)(1)(2) $483.25 Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident. $483.25(a)(1) in making , and $483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT IS NOT MET as evidenced by: Based on observations, interviews, and record review, the facility failed to ensure 1 of 1 sampled resident with a voiced complaint of being unable to hear, received treatment to maintain her ability to hear. The findings included: A review of the Centers for resources on reducing the risk of Control (CDC) preventing or correcting hearing loss. Hearing loss is a known factor that increases a person's risk for (Reducing Risk for and CDC – published ), Hearing loss leads people to be less socially engaged which consequently decreases intellectual stimulation. A review of the medical record revealed that Resident #93 was admitted to the facility with Severe, Without Behavioral Disturbance, , Unspecified Disturbance, and , A Minimum Data Set (MDS) assessment dated Resident #93 had a assessment revealed that of F0685 IMMEDIATE CORRECTIVE ACTION: /2026 1. Resident # 93, were assessed by RN on duty and Md was informed of family concern that resident might need wax removed from . MD gave an order for 3 drops three times a day for clogged for 3 days. On consultation for the resident. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident with hearing may be affected by this deficient practice. 2. DON/ADON completed a comprehensive audit on for residents with hearing to identify if any other residents are in need of wax removal /consult. No other residents were identified as needing consultation. SYSTEMATIC CHANGES: 3. On and ongoing the facility Licensed nurses were re-educated by DON/ADON / SW on identifying residents hearing and vision needs and referring to Physician for consultations. MONITORING: 4. The Social Services Director will complete quality review audits of residents to ensure all residents with hearing that are in need of a vision /hearing consult are addressed timely, weekly x 4 weeks then every two weeks to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

F0685 SS = D Continued from page 11 10. This indicated she had moderate dated . Review of Section B of the MDS assessment documented Resident #93 had minimal difficulty hearing and did not have review of Resident #93's medical records showed no plan of care initiated to address this resident's difficulty hearing. An observation on at 1:15 PM revealed that Resident #93 was sitting up on the side of her bed when the surveyor entered the room. The surveyor asked the resident how she was, and the resident said, "I can't hear you". The surveyor continued to interview the resident and the resident repeated, "I can't hear you". Three times the resident's response was "I can't hear you". After the unsuccessful attempt to interview Resident #93, the surveyor used a motion to communicate to the resident that it was ok she didn't hear what was said. The surveyor turned to leave the room, and the resident looked frustrated and quickly laid down in her bed. An interview with Resident #93's family member conducted on at 5:00 PM, revealed that Resident #93 had her wax cleaned out on more than one occasion prior to admission to the facility. He explained that one time after the earwax was cleaned out of her , there was a lot removed, and the dislodged wax was a very long tubular shape. The family member said that after the process, Resident #93 complained the TV was too loud. The family member said that when he visited the resident on , he requested that nursing follow-up on cleaning out her wax. When asked if he also requested that prior to , the family member explained that he initially requested it approximately 2 weeks ago. He did not remember which nurse he spoke to. An interview was conducted on at 11:40 AM with Staff B, who was a Licensed Practical Nurse and the Unit Manager. When asked if there was a plan in place to address the family member's two requests to have Resident #93's earwax cleaned out, Staff B said she was not aware of those requests. She searched through Resident #93's medical records. She did not see any notes about the request. She did not find any documentation or orders to follow-up on earwax removal for Resident #93.

F0690 SS = D Bowel/ , . , . CFR(s): 483.25(e)(1)(-3)

F0690 IMMEDIATE CORRECTIVE ACTION: /2026 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

F0690 SS = D Continued from page 12

F0690 Continued from page 12 $483.25(e) $483.25(e)(1) The facility must ensure that resident who is of and receives services and assistance to maintain unless his or her clinical condition is or becomes such that $483.25(e)(2)For a resident with based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an is not unless the resident's clinical condition demonstrates that was necessary; (ii) A resident who enters the facility with an or subsequently receives one is assessed for removal of the as soon as possible unless the resident's clinical condition demonstrates that is necessary; and (iii) A resident who is of receives appropriate treatment and services to prevent and to restore to the extent possible. $483.25(e)(3) For a resident with fecal based on the resident's comprehensive assessment, the facility must ensure that resident who is of receives appropriate treatment and services to restore as much normal function as possible. This REQUIREMENT IS NOT MET as evidenced by: Based on observation, record review and interview the facility failed to ensure care and services in failure to have an anchor for a , and failure to follow the physicians order by notifying the physician of the change in the color of the for Resident #128. The findings included: Observations of Resident #123 on and at 10:29 AM revealed a dark orange in color, at 1:00 PM bag containing was noted to be dark orange in color. The water cup at the bed was observed to be full. 1. Resident # 128, was assessed by RN on duty and Physician # 128, was assessed the dark on anchor was added immediately for resident #128. The resident experienced no adverse outcome related to alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident with a has the potential to be affected by alleged deficient practice 2. DON/ADON completed a comprehensive audit on for residents with to ensure that it is properly anchored and that nurses are reporting abnormal changes to physician timely. No other residents were identified. SYSTEMATIC CHANGES: 3. On and ongoing, the facility Licensed nurses and CNAs were re-educated by DON/ADON/ on Care and Monitoring residents for changes to report to Physicians. MONITORING: 4. The DON /Designee will complete quality review audits of residents with to ensure that are properly anchored and that nursing staff are reporting abnormal changes to physician timely daily x 2 weeks, weekly x 6 weeks then then monthly x 1 to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 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

F0690 SS = D Continued from page 13 Observations of Resident #123 on at 9:00 AM revealed a bag containing was noted to be dark brown in color. There was no anchor attached to the tubing. The water cup at the bed was observed to be full. Review of the electronic record for Resident #128 revealed that she was admitted to the facility on with a diagnosis to include and of the physician's orders revealed . A review Monitor Q (every) Shift: Notify the physician appearance (color, consistency, odor, etc.) and/or no appearance, color, consistency, odor, etc.) and/or no care plan documents the resident has a risk for related to use of secondary injury to a diagnosis of . The interventions included encourage and assist resident with fluid intake as tolerated; Monitor for signs and symptoms of bacteriuria; . cloudiness, no output, deepening of tinged color, increased, . increased temp, . foul smelling, . chills, . change in behavior, change in eating patterns. Report abnormalities to nurse/MD as needed; and Teach resident or caregiver on use of importance of adequate fluids, signs and symptoms of and cloudy output, . ., and foul-smelling . such as During an interview on at 9:30 AM with Staff I, LPN (Licensed Practical Nurse) the surveyor asked the nurse to come to the resident's room and to look at her . The nurse confirmed that the resident did not have an anchor. The surveyor then asked what the process is if the color. She stated the resident needs hydration, she would offer her water and she would reach out to the physician. The surveyor then asked if she had reached out to the physician since the resident's has been like this since Monday and today (Thursday), she replied no, but I will. During an interview on at 10:41 AM with the Director of Nursing (DON) he stated that he called the resident's physician and he ordered ( ) fluids 1 liter (1,000 ml) to run at 100/ml (milliliters) for 1 hour for 1 liter. /CMP ( /Comprehensive Panel) and with . He stated the nurse should have called the physician, and there is an order to do so. The DON added that an anchor should always be on, unless the resident refuses it or doesn't

F0690 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

F0690 SS = D Continued from page 14 want it. F0690

F0695 SS = D CFR(s): 483.25(i) § 483.25(i) , care, including care and suctioning. The facility must ensure that a resident who needs , care, including care, including suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT IS NOT MET as evidenced by: Based on policy review, observation, interview and record review, the facility failed to ensure appropriate care and services for sampled residents as evidenced by failure to follow physicians orders for administration and parameters, and to maintain sanitary conditions of the tubing for Resident #41, and to maintain a clean concentrator filter and change per request for Resident #1. The findings included: Review of the policy, " Administration" dated , documented in part, "1. Verify that there is a physician's orders for this procedure. Review the physician's orders or facility protocol for administration." 1) Review of the record revealed Resident #1 was admitted to the facility with diagnoses to include acute failure with (a lack of supply to the ) and (a progressive causing sever breathing difficulties). Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a ( ) score of 14, on a 0 to 15 scale, indicating the resident . This same MDS also documented the resident used supplemental Review of the physician orders revealed an order dated for continuous at 2 liters per minute for Resident #1 for a diagnosis of . Further review of the orders and care plans lacked any instructions 1.Resident #1 was provided with a new tubing immediately. Resident # 41 concentrator filter was changed immediately. The residents 1 and #41 experienced no adverse outcome related to alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident receiving has the potential to be affected by alleged deficient practice 2. DON/ADON completed a comprehensive audit on for residents receiving to ensure maintain sanitary conditions of tubing and ensure that concentrator filter is clean. No other residents were identified. SYSTEMATIC CHANGES: 3. On and ongoing, the facility Licensed nurses and CNAs were re-educated by DON/ADON on Care of residents receiving with Emphasis on ensuring maintaining sanitary conditions of tubing and ensure that concentrator filter is clean. concentrators will be placed on a monthly schedule to ensure filters are cleaned by the environmental department. MONITORING: 4. The DON /Designee will complete quality review audits of residents with weekly x 4 weeks then monthly x 2 to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 106091 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

F0695 SS = D Continued from page 15 for cleaning the .. concentrator filter. During an interview and observation on at 12:35 PM, Resident #1 stated he had been asking for new tubing as the one he had was not working well. Observation of the tubing revealed a kink in the tubing as it was bent down near where it connected to the concentrator. The .. was running at 5 liters per minute. When asked if this was the correct rate of administration, the resident stated and. Observation of the filter revealed it was gray and dust laden. Photographic evidence obtained. During an observation on at 3:40 PM, the .. filter and tubing remained the same. During an interview on at 4:16 PM, when asked about the process for maintenance regarding changing the tubing and cleaning the filters, Staff B, Licensed Practical Nurse (LPN) First Floor Unit Manager, stated the night shift does both on Wednesdays. The Unit Manager observed the resident's concentration filter and bent .. tubing and agreed with the findings. 2) Review of the record revealed Resident #41 was admitted to the facility on and with diagnoses including .Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a ( ) score of 15, on a 0 to 15 scale, indicating intact cognition. Review of the Physicians Orders for Resident #41 revealed the following orders both dated .. NCVMask, Encourage and assist resident to use .. at 2 Liters/Min via Canula as needed for .. saturation less than 92% as needed, and tubing/mask/bag Q week and as needed (PRN) every night shift every Wednesday and as needed. During observations on at 10:49 AM, Resident #41 was in bed with the .. concentrator running at 2 Liters, and the floor. Resident #41 had his breakfast tray in front of him on his bedside table. During another observation at 1:25 PM, Resident #41 was sitting upright in bed with his lunch tray on his bedside table and his tubing was still located on the floor. Photographic Evidence Obtained. Resident #41 pushed his call bell and Staff G: Restorative Aide came in and after surveyor intervention Staff G noticed that the was located on the floor while the machine was running. Staff G picked up the tubing off 106091 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

F0695 SS = D Continued from page 16 Continued from page 16 the floor and hung the tubing on the drawer of the bedside table instead of disposing of it. Staff G went to get Staff F, Licensed Practical Nurse (LPN) to let her know that Resident #41 did not have his on. Staff G failed to inform Staff F that the tubing was found on the floor. Staff F came into Resident #41's room and attempted to reinsert the tubing into Resident #41's and was advised by the surveyor that the tubing had been on the floor and Staff F stated that she found it on hanging on the drawer of the bedside table and was not informed that it had been on the floor. Staff F was asked if she should take Resident #41's satisfaction. She had not for at least 2 hours. Resident #41 stated to Staff F that he is now on room air and does not need Staff F retrieved the from her cart and Resident #41's saturation level was 98 percent. Staff F advised Resident #41 that he had a Physician's order for and encouraged him to put the new tubing on and that she would contact his doctor to see if Resident #41 still needs and Resident #41 gave in and agreed to let Staff F assist him with putting the in his Observations on at 08:55 AM, and on at 3:20 PM, on at 9:58 AM, and on at 10:23 AM, and the revealed Resident #41 was wearing the concentrator was running at 2 Liters. Review of Vitals- Resident #41's Saturation revealed that Saturation was above 92 percent 22 out of 23 documented assessments while on room air 10 times and while on at 2 Liters 12 times. An interview was conducted on at 12:35 PM with Staff F (LPN) who was asked about the order for Resident #41. She stated he was on 2 liters of continuous and then reviewed the order and stated that she was wrong that the order was for 2 liters of if residents saturation was below 92 percent. She was asked what should have occurred on when Resident #41's saturation was 98 percent. Staff F stated that she shouldn't have put the on Resident #41 since his was at 98 percent. She then confirmed that the order for Resident #41 had never been for continuous An interview was conducted on at 1:25 PM with Staff G, restorative aide, who confirmed that he found the #41's room and had forgot to tell Staff F that it was in Resident on the floor. He stated that he should have just thrown on the floor. 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

F0695 SS = D Continued from page 17 out the tubing and not hung it on the bedside table drawer.

F0695

F0755 SS = D Pharmacy Svrcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3) $483.45 Pharmacy 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 procedures 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 drugs are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is NOT MET as evidenced by: Based on record review and interview the facility failed to ensure controlled substance reconciliation for 4 of 6 sampled residents as evidenced by the failure to document both on the declining inventory sheet and the Medication Administration Record (MAR) for Residents #4, #110 and #18; and failure to remove from inventory and destroy a discontinued controlled medication for Resident #12.

F0755 IMMEDIATE CORRECTIVE ACTION: /2026 1. Resident # 4, #110, #18 and #12 were assessed by RN on duty and experienced no adverse outcome related to the alleged deficient practice. The discontinued medication for resident #12 was immediately removed from inventory and destroyed by the Director of Nursing. Staff I and Staff C were Counseled by the Director of Nursing on ensuring that components of F0755 are followed with emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the Medication Administration Record. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: All residents in the facility receiving controlled substance medications have the potential to be affected by the alleged deficient practice. A facility wide comprehensive review was completed to confirm that all residents receiving controlled substance medication had their medication administration documented on both the declining inventory sheet and the Medication Administration Record. 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 component of 0755 with emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the Medication Administration Record during medication administration and the removal of discontinued medication from the medication cart. The pharmacy Consultant/DON designee conducted medication pass competencies with active licensed nurses to ensure competency and compliance. Newly hired nursing staff will be educated during orientation on Med-Pass and documentation practices as it relates component of 0755 with emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

F0755 SS = D Continued from page 18 The findings included: Review of the policy titled, "4.0 Schedule II Controlled Substance Medication" documented in part, "Dispensing of Controlled Dangerous Substances" ... 3. A declining inventory sheet will be provided with each dispense prescription for controlled dangerous medications. The form will contain the following information: patient name, medication name, medication strength, dosage form, name of prescribing physician, amount dispensed, prescription number and date dispensed. ... 5. When a Controlled Dangerous Substance medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. ... Discontinuation of Controlled Substances: 1. Controlled medications, which have been discontinued due to physician order, patient charge, or patient must be destroyed per facility policy." 1) During a controlled medication review on the first floor 300 wing medication cart on at 1:03 PM, 15 mg (milligrams) for Resident #4 and corresponding MAR was reviewed with Staff L, Licensed Practical Nurse (LPN). Review of the MAR documented Resident #4 was given one tablet of the tablet on at 5:29 AM. The corresponding declining medication record for the 15 mg tablets of lacked any entry for that administration. The declining medication record jumped from at 6:27 PM to at 1:04 PM. When asked the process for administration of controlled medications, Staff L confirmed the medication must be documented on the declining medication record and the MAR and agreed with the findings. 2) During a controlled medication review on the first floor 100 wing medication cart on at 1:42 PM, 5/325 mg tablets for Resident #110 and corresponding MAR was reviewed with Staff I, LPN. The MAR documented the was administered on at 2:34 PM and 7:47 PM and there was no corresponding documentation on the declining medication record. The declining medication record documented an entry on at 10:47 PM with no corresponding documentation on the MAR. Staff I F0755 Continued from page 18 Medication Administration Record during medication administration and the removal of discontinued medication from the medication cart. MONITORING: Quality Review Tools will be utilized by the Unit Manager/designee daily times 2 weeks then weekly x 8 to include all nursing carts to support compliance. 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 maintenance

F0755 SS = D Continued from page 19 agreed with the findings. F0755 3) During the continued controlled medication review on the first floor 100 wing medication cart on at 1:42 PM, the declining inventory sheet for the 10/325 mg tablets for Resident #12 and corresponding MAR was reviewed with Staff I, LPN. There were two declining medication records on the medication cart. One for the medication to be administered every four hours and one for every six hours, both on an as needed basis. Review of the declining medication record for the every 6 hour administration had seven entries between the dates of and in which five different nurses documented they had pulled out the medication to administer to Resident #12. Review of the MAR lacked any order for the to be given every 6 hours. During an interview at this time, when asked the process for the controlled medications once the physician discontinues an order, Staff I stated the medication should be removed from the cart and given to the supervisor for destruction. 4)Review of the record revealed Resident #18 was initially admitted to the facility with the and other diagnoses included, and low primary diagnosis of . . . Review of the current Minimum Data Set (MDS) assessment dated documented Resident #18 had a ( ) score of 14, on a 0 to 15 scale, indicating the Resident was Review of Resident #18's care plan dated documented "Focus: Resident receives opiate medications related to: not managed by alternate interventions. Goal: Resident risk for adverse effects related to use of . will be minimized through next review date. Interventions: Administer medication as prescribed by the physician (See current MAR & Physician orders for current dosage.)" Review of Resident #18's current orders documented, " Tablet 50 MG -Give 1 tablet by every 8 hours as needed for moderate and severe, pain Review of the discontinued orders documented, " Tablet 50 MG -Give 1 tablet by every 8 hours 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 20 as needed for moderate and severe , "start date ; discontinued date A medication storage review was conducted for Resident #18 on at 8:50 AM with Staff C, LPN (Licensed Practical Nurse) where cart #3 was reviewed for medication storage and were reconciled. Upon the review of Resident #18's medication, Tablet 50 MG (a ) the last 3 administrations log as follows: "Date: :Time: 11:00; On 6; Amount given 1; Remaining 5 Date: :Time: 09:21; On 5; Amount given 1; Remaining 4 Date: :Time: 14:02; On 4; Amount given 1; Remaining 3" A verification count was done with Staff C, LPN in which both surveyor and nurse counted 3 remaining pills in the medication pack as per the documented log. The MAR/TAR (Medical Administration Record/Treatment Administration Record ) was then reviewed for documentation of the above administrations where the administration and the , administration was not documented in the record. Staff C, LPN was asked to pull up the MAR/TAR on her computer to see if she was able to see the documentation of the administrations; Staff C agreed she could not see it either. On at 9:49 AM, during a side-by-side review of the medication storage findings, the Assistant Director of Nursing (ADON) stated in the month of their system was down and most documentation had to be entered in another location and later provided the documentation for this administration. When asked about the , administration, the ADON pulled up the MAR/TAR and agreed that it was blank. When asked what the process was for logging out a during administration, the ADON stated as you give a medication, it should be signed out both in the log and in the MAR. She agreed that the documentation was not there and should have been documented upon administration.

F0756 SS = D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F0756 IMMEDIATE CORRECTIVE ACTION: /2026 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

F0756 SS = D Continued from page 21 $483.45(c) Drug Regimen Review. $483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. $483.45(c)(2) This review must include a review of the resident's medical chart. $483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is no action change in the medication, the attending physician should document his or her rationale in the resident's medical record. $483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT IS NOT MET as evidenced by: Based on record review and interview, the facility failed to follow pharmacy recommendations for 1 of 5 sampled residents (Resident #96). The findings included: Review of the record revealed Resident #96 was admitted to the facility on . Review of the current

F0756 Continued from page 21 The resident experienced no adverse outcome related to alleged deficient practice. The nurse responsible for discontinuing the received a one-to-one education from the DON on IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident with a drug regimen review has the potential to be affected by the alleged deficient practice. 2. On audit on residents with a drug regimen review to ensure that it was addressed by nurse and completed timely. No other residents were identified. SYSTEMATIC CHANGES: 3. On the facility Director of Nursing was re-educated by the CNO/Pharmacy Consultant on the importance of ensuring that all pharmacy recommendations are reviewed and addressed with the physician when indicated timely for resolution. MONITORING: 4. The DON /Designee will complete quality review audits of residents with a drug regimen review to ensure that pharmacy recommendations are reviewed and addressed by the physician when indicated timely for resolution. Weekly x 4 then monthly x 3 months to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. --- | --- | --- | --- 106091 | | LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 --- | --- | --- | --- | ---

F0756 | Continued from page 22 documented , (an physician order dated , ) 1 mg (milligram) , medication. , was to be administered every 6 hours PRN (as needed) for , . This order lacked any duration or stop date. This order was entered by Staff K, Registered Nurse (RN). | F0756 | | | Review of the pharmacy recommendation for revealed the pharmacist identified the order for the as needed , without a documented stop date or needed duration, and recommended the physician order a stop date. The physician agreed and ordered the medication to be stopped as of the as needed , . As of the survey date on order remained active. | | | | During an interview on at approximately 10:00 AM, when asked the duration of use for that was ordered as needed, Staff K, RN, stated sometimes they (the physicians') order it with a specific timeframe and other times not. When asked if he was aware of any regulation for , medications related to the duration of use, the RN stated he did not. | | | | During an interview on at 10:38 AM, when asked the duration of use for as needed , Staff B, Unit Manager, stated they usually order PRN for 14 days, but the doctor may order it longer with justification and a definite timeframe, like 30 days. The Unit Manager agreed with the findings. | | | | During an interview on at 11:25 AM, when asked about the duration of PRN , Staff M, psychiatrist, stated, "14 days." When asked about Resident #96's order, the psychiatrist stated that order came from the hospital and the nurse's entered it in as it was there. | | |

F0759 | Free of Medication Error Rts 5 Prcnt or More | F0759 | IMMEDIATE CORRECTIVE ACTION: | /2026 SS = D | CFR§: 483.45(f)(1) | | | | $483.45(f) Medication Errors. | | | | The facility must ensure that its- | | | | $483.45(f)(1) Medication error rates are not 5 percent or greater; | | | | This REQUIREMENT IS NOT MET as evidenced by: | | | | Based on observation, interview and record review, the | | | | | 1. Resident # 116, physician was notified immediately and an order received to administer additional dose of which was completed on . The resident received additional as ordered. The resident experienced no adverse outcome related to alleged deficient practice. | | | | Staff K was counseled by the Director of Nursing and received one-to-one education on . | | LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

F0759 SS = D Continued from page 23 medication error rate was 8 percent. Two medication errors were identified while observing a total of 25 opportunities, affecting 1 of 6 residents observed (Residents #116). The findings included: A medication pass observation for Resident #116 was made on at 9:19 AM with Staff K, Registered Nurse (RN). The RN pulled 9 pills from the medication cart that included one 1 mg (miligram) (an ) with a 50 ml (milliliters) bag of NS (Normal (NS) to administer. Then verified the 9 pills with one medication prior to the room. The RN gave the 9 pills to Resident #116. The RN then started to prepare the seal between the NS bag and vial of medication, by breaking the squeezing the NS bag to allow fluid to enter the vial of and mixed the solution. The RN then turned the bag and vial to the upright position but failed to squeeze the NS bag prior to allow the vial to empty in the NS bag to be administered. The RN hooked the tubing to the resident's line and started the pump to administer and left the room at 9:50 AM. Upon leaving the room a faint beeping was heard from the machine, and it was observed that occluded (the medication could not infuse), but the RN continued out of the room. An observation at this time revealed the vial remained full of the now mixed medication and was not in the bag of NS, thus was unable to be administered to the resident. A partially empty bag of NS was hanging from the pole. Continued observation of the room was made by the supervisor. At 9:57 AM a Certified Nursing Assistant went to the resident's room with the linen cart and entered the room to provide care. At 10:26 AM Staff K, RN, passed by the room but did not check the went to the resident's door stating that he would have to come later at 10:34 AM a running. The was beeping. At 10:37 AM the RN stated that the was heard telling Resident #116 the room, removed the and tubing from the machine, and threw the set into the garbage. Photographic evidence obtained. On at 10:40 AM, when asked if the had completed, Staff K, RN, stated it did. Upon retrieval of the from the trash, the NS that was in the tubing and bag drained out onto the floor and the vial remained full of the medication. Photographic evidence obtained. When told the medication had not been infused as the vial was full

F0759 Continued from page 23 IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident receiving Medication Administration has the potential to be affected by the alleged deficient practice. 2. DON/ADON completed a comprehensive audit on residents Medication Administration Record on to ensure that the residents received medication as ordered by nurse. No other residents were identified. SYSTEMATIC CHANGES: The Assistant Director of Nursing Pharmacy consultant conducted ongoing in-services with Licensed nursing staff on facility practices as it relates Medication Administration, Following the Six Rights. The pharmacy Consultant/DON designee will conduct medication pass competencies with active licensed nurses to ensure competency and compliance. Newly hired nursing staff will be educated during orientation on Med-Pass and documentation practices and to ensure competency. MONITORING: Quality Review Tools will be utilized by the Unit Manager/designee daily times 14 days, then weekly x 6 weeks to support compliance. A minimum of 10 patients on each unit will be reviewed. 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. 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

F0759 SS = D Continued from page 24 and the pump had been beeping occlusion, the RN argued and disagreed, stating he had squeezed the bag. When told again that he did squeeze the bag, but the medication did not go into the 50 ml bag to infuse, as he did not invert the vial upright, the RN disagreed. The RN returned to the medication cart. The RN was asked to pull the pack and asked if he administered one or two tablets. The RN confirmed he only administered one tablet, and the physician order was for two tablets. Review of the record revealed the order dated to administer two tablets of 1 mg daily. On at 10:52 AM, Staff B, Licensed Practical Nurse (LPN)/Unit Manager was taken to the resident’s room to observe the and made aware of the observation. The Unit Manager agreed with the findings.

F0759 Florida Department of Health PRINTED: 04/20/2026 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0000 INITIAL COMMENTS N0000 (blank) /2026

N0006 SS = C Posting Staff CFR(s): 400.23(3)(b)4, FS (blank) (blank) A re-licensure and complaint survey complaint, #2025019422 and #2026002348 was conducted at Luxe at Wellington Rehabilitation Center. on The facility had deficiencies at the time of the investigation. complaint #2026002348 was substantiated with a deficiency cited at n201. Complaint #2025019422 was not substantiated. Each nursing home facility must document compliance with staffing standards as required under this paragraph and post daily the names of licensed nurses and certified nursing assistants on duty for the benefit of facility residents and the public. Facilities must maintain the records documenting compliance with minimum staffing standards for a period of 5 years and must report staffing in accordance with 42 C.F.R. s. 483.70(q). This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observation and interviews, the facility failed to post names of staff on duty for 4 out of 4 days, during the survey. The findings included: During daily observations on noted the names of staff on duty were not posted for facility residents and the public to see. An interview was conducted with the Assistant Director of Nursing (ADON) who was asked where someone would find the names of staff who were working today. The ADON stated that the white binder labeled "Staffing daily sheets and assignments" that is located at the nursing station has that information. The ADON was asked if that is the only location that the information is found and she stated, "Yes." IMMEDIATE CORRECTIVE ACTION: 1. The staffing assignment was immediately posted on each unit as required daily with the names of licensed nurses and certified nursing assistants on duty for the benefit of facility residents and the public. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Residents had the potential to be affected by the alleged deficient practice. All units were checked to ensure that Assignment was posted by the ADON SYSTEMATIC CHANGES: 3. On licensed nurses and staffing Coordinator were re-educated by DON/ADON on ensuring that the staffing assignment is posted on each unit as required daily with the names of licensed nurses and certified nursing assistants on duty for the benefit of facility residents and the public. MONITORING: 4. The Staffing Coordinator/ designee will complete a quality review audit of assignment board of staff on duty daily in every unit as required daily x 4 weeks then weekly x 4 to ensure ongoing compliance, findings Office of Primary Care and Health Systems Management California Department of Health PRINTED: 04/20/2026 03/12/2026 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0066 Continued from page 1 N0066 Continued from page 1 will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. SS = C An interview was conducted on the 1st floor unit with Staff N, 1st floor Unit Clerk-who was asked if someone would find the names of staff who were working today. Staff N stated the names are in the white binder labeled "Staffing daily sheets and assignments" that is located at the nursing station. Staff N was then asked if a resident's family member wanted to see who was working with their family member how would they know. Staff N stated we would look in the binder for them. Staff N was asked if the names of staff working today are posted anywhere. She stated, "No."

N0090 Pharmacy Policies and Procedures N0090 IMMEDIATE CORRECTIVE ACTION: /2026 SS = D CFR(s): 59.4-4.112(1), FAC (1) The nursing home licensee must adopt procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on record review and interview the facility failed to ensure controlled substance reconciliation for 4 of 6 sampled residents as evidenced by the failure to document both on the declining inventory sheet and the Medication Administration Record (MAR) for Residents #4, #110 and #18; and failure to remove from inventory and destroy a discontinued controlled medication for Resident #12. The findings included: Review of the policy titled, "4.0 Schedule II Controlled Substance Medication" documented in part, "Dispensing of Controlled Dangerous Substances: ... 3. A declining inventory sheet will be provided with each dispense prescription for controlled dangerous medications. The form will contain the following information: patient name, medication name, medication strength, dosage form, name of prescribing physician, amount dispensed, prescription number and date dispensed. ... 5. When a Controlled Dangerous Substance medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered and the amount of medication remaining and his/her 1. Resident # 4, #110, #18 and #12 were assessed by RN on duty and experienced no adverse outcome related to the alleged deficient practice. The discontinued medication for resident #12 was immediately removed from inventory and destroyed by the Director of Nursing. Staff I and Staff C were Counseled by the Director of Nursing on ensuring that components of F0755 are followed with emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the Medication Administration Record. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: All residents in the facility receiving controlled substance medications have the potential to be affected by the alleged deficient practice. A facility wide comprehensive review was completed to confirm that all residents receiving controlled substance medication had their medication administration documented on both the declining inventory sheet and the Medication Administration Record. 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 component of 0755 with Florida Department of Health PRINTED: 04/20/2026 03/12/2026 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0090 SS = D Continued from page 2 Initials ... Discontinuation of Controlled Substances: 1. Controlled medications, which have been discontinued due to physician order, patient discharge, or patient must be discarded per facility policy.* 1) During a controlled medication review on the first floor 300 wing medication cart on at 1:03 PM, the declining inventory sheet for (milligrams) 15 mg was reviewed with Staff L, licensed and corresponding MAR was reviewed with Staff L, Licensed Practical Nurse (LPN). Review of the tablet of the MAR documented Resident #4 was given one tablet of the tablet on 5:29 AM. The corresponding declining medication record for the 15 mg tablets of lacked any entry for that administration. The declining medication record jumped from at 6:27 PM to at 1:04 PM. When asked the process for administration of controlled medications, Staff L confirmed the medication must be documented on the declining medication record and the MAR and agreed with the findings. 2) During a controlled medication review on the first floor 100 wing medication cart on at 1:42 PM, the declining inventory sheet for the tablets of Resident #110 and corresponding MAR was reviewed with Staff I, LPN. The MAR documented the was administered on at 2:34 PM and 7:47 PM was there was no corresponding documentation on the declining medication record. The declining medication record documented an entry on at 10:47 PM with no corresponding documentation on the MAR. Staff I agreed with the findings. 3) During the continued controlled medication review on the first floor 100 wing medication cart at 1:42 PM, the declining inventory sheet for the 10/325 mg tablets for Resident #12 and corresponding MAR was reviewed with Staff I, LPN. There were two declining medication records for the medication cart. One for the medication to be administered every four hours and one for every six hours, both on an as needed basis. Review of the declining medication record for the every 6 hour administration had seven entries between the dates of and , in which five different nurses documented they had pulled out the medication to N0090 Continued from page 2 emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the Medication Administration Record during medication administration and the removal of discontinued medication from the medication cart. The pharmacy Consultant/DON designate conducted medication pass competencies with active licensed nurses to support competency and compliance. Newly hired nursing staff will be educated during orientation on Med-Pass and documentation practices as it relates component of 0755 with emphasis on ensuring controlled substance reconciliation with documentation both on the declining inventory sheet and the Medication Administration Record during medication administration and the removal of discontinued medication from the medication cart. MONITORING: Quality Review Tools will be utilized by the Unit Manager/designee daily times 2 weeks then weekly x 8 to include all medication carts to support compliance. 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 maintenance 03/12/2026 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

N0090 SS = D Continued from page 3 administer to Resident #12. Review of the MAR lacked any order for the to be given every 6 hours. During an interview at this time, when asked the process for the controlled medications once the physician discontinues an order, Staff I stated the medication should be removed from the cart and given to the supervisor for destruction. 4) Review of the record revealed Resident #18 was initially admitted to the facility with the and other primary diagnosis of diagnoses included. . . Review of the comprehensive assessment dated documented Resident #18 had a ( ) score of 14, on a 0 to 15 scale, indicating the Resident was . Review of Resident #18's care plan dated documented "Focus: Resident receives opiate medications related to: not managed by alternate interventions. Goal: Resident risk for adverse effects related to use of will be minimized through next review date. Interventions: (Administer medication as prescribed by the physician (See current MAR & Physician orders for current dosage.) Review of Resident #18's current orders documented, " Tablet 50 MG -Give 1 tablet by every 8 hours as needed for moderate and severe, - pain " dated Review of the discontinued orders documented, " Tablet 50 MG -Give 1 tablet by every 8 hours as needed for moderate and severe, - start date ; discontinued date A medication storage review was conducted for Resident #18 on at 8:50 AM with Staff C, LPN (Licensed Practical Nurse) where cart #3 was reviewed for medication storage and were reconciled. Upon the review of Resident #18's medication, Tablet 50 MG (a the last 3 administrations were documented on ) log as follows: " Date: :Time: 11:00: On 6; Amount given 1; Remaining 5 Date: :Time: 09:21: On 5; Amount given 1; Remaining 4 Date: :Time: 14:02: On 4; Amount given 1; Remaining 3"

N0090 | California Department of Health 03/12/2026 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

N0090 SS = D Continued from page 4

N0090 A verification count was done with Staff C, LPN in which both surveyor and nurse counted 3 remaining pills in the medication pack as per the documented log. The MAR/TAR (Medical Administration Record/Treatment Administration Record ) was then reviewed for documentation of the above administrations where the administration and the administration was not documented in the record. Staff C, LPN was asked to pull up the MAR/TAR on her computer to see if she was able to see the documentation of the administrations. Staff C agreed she could not see it either. On at 9:49 AM, during a side-by-side review of the medication storage findings, the Assistant Director of Nursing (ADON) stated in the month of their system was down and most documentation had to be entered in another location and later provided the documentation for this administration. When asked about the administration, the ADON pulled up the MAR/TAR and agreed that it was blank. When asked what the process was for logging out a during administration, it should be signed out both in the log and in the MAR. She agreed that the documentation was not there and should have been documented upon administration.

N0181 SS = D Class III Right to Civil, Religious Liberties & Choice CFR(s): 400.022(1)(a), FS (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (a) The right to civil and religious liberties, including knowledge of available choices and the right to independent personal decision, which will not be infringed upon, and the right to encouragement and assistance from the staff of the facility in the fullest possible exercise of these rights. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on record review and interviews, the facility

N0181 IMMEDIATE CORRECTIVE ACTION: 1.Resident #129 was offered and received a shower on by nursing staff assigned for care. Resident preference was updated and is being followed by staff. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Residents that has a preference for showers have the potential to be affected by the alleged deficient practice 2. DON/ADON completed a comprehensive audit on for residents to ensure that resident's shower preference was identified and plan of care updated to reflect resident's Shower preference. SYSTEMATIC CHANGES: /2026 STATE FORM LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 APPROPRIATE DEFICIENCY)

N0181 Continued from page 5 failed to honor the shower preference and schedule for 1 of 4 sampled residents reviewed for choices for 1 (Resident#129). The findings included: Review of the electronic record for Resident #129 revealed she was admitted to the facility on Record review revealed the resident's Care Plan documented the following for her ADLs (Activities of Daily Living): Resident has an ADL, self-care related to diagnosis of Cholelithiasis, ADL needs and participation varies over the course of the day/week, generalized, balance, Limited Mobility. The interventions included Encourage and assist with all ADL tasks as indicated and as tolerated by resident and based on resident's strengths: Encourage resident to do as many ADL tasks for themselves as possible. ADL care, the resident may need assistance; CNA (Certified Nursing Assistants) Bathing: The resident needs assist of based on fatigue. Further review of her record documented her shower/bathe schedule were Monday, Wednesday and Friday. Her task sheet documents the shower/bathe schedule documented a "yes" next to . The task sheet does not document if this was a shower or bath. A review of a task sheet titled, bath revealed the dates . There were no check marks under the word "showers". Under the word "sponge bath", there was documentation indicating the resident had one on /26 and . On the schedule documented the resident had a full body bath. During an interview on at 9:10 AM, Resident #129 resident was alert and oriented and able to respond to all questions asked. She stated she has never had a shower and wants one. She expressed that she really wants her hair washed. She stated that the full sponge bath she had, she did herself. During an interview on at 9:24 PM with the Regional MDS (Minimum Data Set) Coordinator, she reviewed the shower book and could not find any documentation of showers for Resident #129. She then went into the resident's room and the resident advised her, she wants a shower after lunch. During an interview on at 9:45 AM with Staff J, Certified Nursing Assistant, she was asked about Resident #129's shower schedule. Staff J stated that N0181 Continued from page 5 3. On licensed nurses and CNAs were re-educated by DON/ADON on the components of F0561 with emphasis on ensuring that resident's shower preference and scheduled is honored and informing nurses of refusals to ensure care plan is updated to reflect changes/refusals. Newly admitted residents will be offered a choice of shower and/or bath with a schedule as preferred. Preferences and refusal of care will be reviewed at daily morning meeting 5x weekly to ensure ongoing follow up and resolution. MONITORING: 4. Director of Nursing/ADON will complete random daily quality review audits of residents' shower preferences to ensure it is honored for two (2) weeks on all units, then weekly for two (2) months to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained.

N0181 SS = D Continued from page 6 she hasn't asked her (Resident #129), but she hasn't asked for one. N0181

N0201 SS = D Right to Adequate and Appropriate Health Care CFR(s): 400.022(1)(j). FS (l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational and rehabilitative activities; and discharge planning and aftercare, consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. This LICENSURE REQUIREMENT is NOT MET as evidenced by: A. Based on policy review, observation, record review, and interview, the facility failed to ensure care for 2 of 5 sampled residents reviewed for Activities of Daily Living, as evidenced by the failure to trim and clean the ___ of Resident #1 and Resident #21. The findings included: Review of the facility policy titled, "Activities of Daily Living (ADLs), Supporting," reviewed ___ documented in part, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene." 1) Review of the record revealed Resident #1 was admitted to the facility on ___ Review of the current Minimum Data Set (MDS) assessment dated documented the resident had ( ___ ) score of 14, on a 0 to 15 scale, indicating the resident was ___ This same MDS also documented the resident needed partial ___ from staff for personal hygiene. Review of the current care plan initiated on and revised on ___ documented the resident had an ADL self-care ___ , and participation varied, medical conditions. This care plan documented the resident may need limited to ___ from staff for all ADL care. During an interview and observation on ___ at ___ N0201 IMMEDIATE CORRECTIVE ACTION: 1. Resident #1, and resident #21 ___ were cut and trimmed on ___ by nursing staff assigned for care. 2. Resident # 4, #116, were assessed by RN on duty and experienced no adverse outcome related to the alleged deficient practice. Resident #127 was discharged on from facility. Staff K and Staff H received a one-to-one education from the ADON regarding coordinating care with consultant physician with emphasis on ensuring medications are administered as ordered. 3. Resident # 93, were assessed by RN on duty and Md was informed of family concern that resident might need wax removed from ___ On ___ 3 drops three times a day for clogged for 3 days. MD gave an order for ___ consultation for resident. 4. Resident # 128, was assessed by RN on duty and Physician addressed the dark ___ The resident experienced no adverse outcome related to alleged deficient practice. 5. Resident #1 was provided a new ___ tubing immediately. Resident #41 ___ concentrator filter was changed per request immediately. The resident #1 and #41 experienced no adverse outcome related to alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: 1. DON/ADON completed a comprehensive audit on for residents' ___ and any identified residents with long ___ were cut and trimmed per resident's preference. 2. DON/ADON completed a comprehensive audit on for residents on ___ medications with parameters and with ___ to ensure physicians orders are carried out as ___ /2026

N0201 SS = D Continued from page 7 12:08 PM, Resident #1 was observed with excessively long with the nail extending nearly a quarter inch past the ends at that length, the resident If he preferred his nails at that length, When asked stated he did not and wanted them clipped. When asked if he offered to assist with nail care, the resident stated they had not. During a supplemental observation on at 3:40 PM, the resident's remained elongated. During an interview on at 4:16 PM, when asked who was responsible for cleaning and trimming the residents' Staff B, Licensed Practical Nurse (LPN) First Floor Unit Manager stated the CNAs (Certified Nursing Assistants) should be cleaning and filing with morning care for their residents. The Unit Manager observed the resident's and agreed with the findings. 2) Record review revealed Resident #21 was admitted to the facility on . Her diagnoses included: ( ), Personal History of without residual , and Need for Assistance with Personal Care. Per the Minimum Data Set (MDS) assessment dated , this resident's score equaled 01. This indicated that Resident #21 had severe Minimum Data Set (MDS) assessment dated showed that Resident #21 required maximal assistance with the ADL to clean herself. An intervention listed in Resident #21's Care Plan for ADL self-care dated , was to keep the resident clean, dry, and well-groomed. An observation of Resident #21 in her room on at 5:30 PM revealed her were long. There was dark brown-black matter beneath her . Some of the extended one quarter to one half an inch past the . Photographic Evidence Obtained. During an interview with Resident #21 on at 5:30 PM it was revealed that she preferred her to be shorter. An observation of Resident #21 in her room on at 1:30 PM revealed that her were long. There was dark brown-black matter beneath her . Resident #21 stuck her left- in the ground meat with gravy that was on her meal plate. Her left- had more brown-black matter than the on her right . Photographic Evidence Obtained. N0201 Continued from page 7 ordered and that resident is have follow up orders to ensure care is provided. 3. Any resident with hearing may be affected by this deficient practice. DON/ADON completed a comprehensive audit for residents with hearing to identify if any other residents are in need of wax removal /consult. No other residents were identified as needing consultation. 4. Any resident with a has the potential to be affected by alleged deficient practice DON/ADON completed a comprehensive audit for residents with to ensure that it is properly anchored and that nurses are reporting abnormal changes to physician timely. No other residents were identified. 5. Any resident receiving has the potential to be affected by alleged deficient practice. DON/ADON completed a comprehensive audit for residents receiving to ensure to maintain sanitary conditions of tubing and ensure that concentrator filter is clean. No other residents were identified. SYSTEMATIC CHANGES: 1. On licensed nurses and CNAs were re-educated by DON/ADON on the components of providing care to residents and informing nurses of refusals to ensure care plan is updated to reflect changes/refusals. Preferences and refusal of care will be reviewed at daily morning meeting 5x weekly to ensure ongoing follow up and resolution. 2. On licensed nurses were re-educated by DON/ADON on the components of F0684 with Emphasis on ensuring physician orders are carried out accurately and timely; for Residents on . Residents with medications with parameters and that has follow up orders to ensure care is provided. The Director of Nursing will review all new orders with

N0201 SS = D N0201 Continued from page 8 Continued from page 8 An interview on at 5:25 PM was conducted with Staff A, CNA, who provided care to Resident #21. When Staff A was asked to describe Resident #21’s She said that they were of medium length. She asked Resident #21 if she would allow her to cut and clean her nails after she finished eating dinner. Resident #21 nodded in agreement and said yes. An observation on Resident #21’s at 9:20 AM revealed that were short and clean. B) Based on observation, interview, and record review, the facility failed to ensure appropriate and timely care and services for 3 of 24 sampled residents as evidenced by the failure to coordinate care with a consultant physician to ensure continued administration for Resident #4; failure to ensure care to the left lower extremity of a #116; and failure to ensure documented readings at the time of administration of an medication with physician ordered parameters for Resident #116; and failure to follow physician ordered parameters for medications for Resident #127. The findings included: 1) Review of the record revealed Resident #4 was admitted to the facility on Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a score of 15, on a 0 to 15 scale, indicating the resident was on an medication. This same MDS documented the resident was on an medication. Review of the current physician order revealed as of Resident #4 was to receive (an ) via once daily until Previous physician orders revealed the resident received the from through The record lacked any evidence of administration or reason for the lack of administration on and A progress note dated confirmed Resident #4 went to the A physician’s order from the ID physician dated documented the resident was to continue the until clinical team at daily morning meeting to ensure accuracy in documentation and that timely follow-up care is carried out. 3. On and ongoing the facility Licensed nurses were re-educated by DON/ADON SW on identifying residents hearing and vision needs and referring to Physician for consultations. 4. On and ongoing, the facility Licensed nurses and CNAs were re-educated by DON/ADON on Care and Monitoring residents for changes to report to Physicians. 5. On nurses and CNAs were re-educated by DON/ADON on Care residents receiving with Emphasis on ensuring maintaining sanitary conditions of tubing and ensure that concentrator filter is clean. concentrators will be cleaned on a monthly schedule to ensure filters are cleaned by the environmental department. MONITORING: 1. Director of Nursing/ADON will complete weekly quality review audits of residents’ care for four (4) weeks, then monthly for two (2) months to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 2. Director of Nursing/ADON will complete quality review audits of residents’ EMAR and ETAR to ensure physician orders are carried out accurately and timely for Medications, - Hypertensive medications with parameters, and that have follow up orders to address, daily x 2 weeks, weekly x 8 weeks to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 3. The SW Director will complete quality review audits of residents to ensure that all residents with hearing that are in need of a vision /hearing consult are addressed timely. weekly x 4 weeks then every two weeks to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. Florida Department of Health PRINTED: 04/20/2026 03/12/2026 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

N0201 SS = D Continued from page 9 During an interview on 04 explained that she had gone to the ID physician last Tuesday ( ), had received written orders to extend for two weeks. Resident #4 stated she took a photo of the order and handed it to the nurse upon return from the consultant physician's office. Resident #4 stated by Friday morning ( ), she was not getting ( ). The resident stated she spoke with a supervisor on that Friday and told her the issue. The supervisor responded she would take care of it, but never heard from her or anyone else again. Resident #4 stated she went through the weekend and Monday without the ( ) for her ( ( ), of her left restarted Monday and they finally got the evening. During an interview on about the process for new orders when a resident goes out to a consultant physician Licensed Practical Nurse (LPN)/Unit Manager, explained when the resident returns from the , they give the new order to a nurse. The Unit Manager stated if the resident does not provide an order, the nurse is to ask the residents if they received one, and if not, they are to document the lack of an order in the medical record. When asked what happened to Resident #4's on through , the Unit Manager stated she was unaware of any issue. When told of the consultant's physician order to continue the return from the office visit, the Unit Manager had no explanation but agreed with the findings. 2) Review of the record revealed Resident #116 was admitted to the facility on . Review of the initial nursing assessment from lacked any skin issues to the resident's left . Review of the weekly skin assessment on documented the resident had a on his left lower . After having sustained a skin checks for mention of on that same day, lacked any and Review of physician orders lacked any order for care to the resident's left . During an observation and interview on at 10:01 AM, a large (approximately 4 inches by 6 inches) white , that was curled up along the edges and had a faded date of was noted to the resident's left . Upon observation N0201 Continued from page 9 4. The DON /Designee will complete quality review audits of residents with to ensure that are properly anchored and that nursing staff are reporting abnormal changes to physician timely daily x 2 weeks, weekly x 6 weeks then then monthly x 1 to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 5. The DON /Designee will complete quality review audits of residents with , weekly x 4 weeks then monthly x 2 to ensure ongoing compliance. Findings will be reported at the monthly quality assurance meeting to ensure substantial compliance is achieved and maintained. 6. Regional Clinical Director will visit facility weekly and complete review of All Quality-of-Care Audits to ensure ongoing compliance x 1month then monthly x3 months. Florida Department of Health PRINTED: 04/20/2026

N0201 SS = D Continued from page 10 a bloody-like area about 2 inches in diameter was seen through the __. When asked how long the had been on his __, the resident stated, "about a week or so." Photographic evidence obtained. During the medication pass observation with Staff K, Registered Nurse (RN), on __ at 9:45 AM, the same __ was noted to the resident's left __. During an observation on __ at 4:09 PM, the same __ remained on the resident's left __. When shown to Staff B, LPN/Unit Manager, she agreed with the findings. 3) Review of the record revealed Resident #116 was admitted to the facility on __ with diagnosis to include essential __. Review of the physician orders revealed as of Resident #116 was to receive the medication 50 mg (milligrams) twice daily at 9 AM and 5 PM, but to hold the medication for a __, less reading) than 100 (the top number of the __, __ reading) or a __. Review of the corresponding Medication Administration Record (MAR) for __ lacked any documented rate readings with the medication. During a medication pass observation for Resident #116 on __ at 9:19 AM, Staff K, Registered Nurse (RN) held the resident's __ because the __ reading was __. Review of the MAR documented a __ reading of __, clearly not taken at the time of the medication pass observation. Further review of the MAR documented daily vital sign reading for the day shift (7 AM to 7 PM) and the night shift (7 PM to 7 AM). This entry lacked any specific time for the vitals, thus there was no way to know if the __ and __ rates were taken with the medication. This documentation also lacked two entries on the day shift to incorporate both doses of medications on that shift. Review of the vital sign summary documentation lacked any vitals at 5 PM for 9 of 11 days. During a side-by-side review of the record and interview on __ at 10:43 AM, Staff B, Unit Manager, agreed with the lack of documented __ and __ rates. 4) Review of the electronic records for Resident #127 N0201 California Department of Health PRINTED: 04/20/2026 Florida Department of Health PRINTED: 04/20/2026 LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0201 N0201 SS = D Continued from page 12 On the 09:00 AM dose of , the was .The diastolic of 50 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. During an interview on at 10:15 AM with the Director of Nursing (DON), he reviewed the MAR (Medication Administration Record) for and acknowledged the findings. During an interview on at 1:02 PM Staff H, LPN (Licensed Practical Nurse) She reviewed the MAR for and stated she would not give it but acknowledged she had a check mark next to the resident's name and gave it when she shouldn't have. C) Based on observations, interviews, and record review, the facility failed to ensure 1 of 1 sampled resident with a voiced complaint of being unable to hear, received treatment to maintain her ability to hear. The findings included: A review of the Centers for Control (CDC); resources on reducing the risk of , includes preventing or correcting hearing loss. Hearing loss is a known factor that increases a person's risk for (Reducing Risk for | and | CDC – published ). Hearing loss leads people to be less socially engaged which consequently decreases intellectual stimulation. A review of the medical record revealed that Resident #93 was admitted to the facility on .Her diagnoses included Unspecified . Unspecified Severity, Without Behavioral Disturbance, . Disturbance, and . A Minimum Data Set (MDS) assessment dated revealed that Resident #93 had a 10. This indicated she had moderate . Review of Section B of the MDS assessment dated indicated that Resident #93 had minimal documented hearing and did not have . A review of Resident #93's medical records showed no plan of care initiated to address this resident's difficulty hearing. An observation on at 1:15 PM revealed that Resident #93 was sitting up on the side of her bed when California Department of Health 03/12/2026 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

N0201 SS = D Continued from page 13 The surveyor entered the room. The resident said, "I can't hear you." The surveyor continued to try and interview the resident how she was, and the resident said, "I can't hear you." Three times the resident's response was "I can't hear you." After the unsuccessful attempt to interview Resident #93, the surveyor used a motion to communicate to the resident that it was ok she didn't hear what was said. The surveyor turned to leave the room, and the resident looked frustrated and quickly laid down in her bed. An interview with Resident #93's family member conducted on at 5:00 PM, revealed that Resident #93 had her wax cleaned out on more than one occasion prior to admission to the facility. He explained that one time after the earwax was cleaned out of her , there was a lot removed, and the dislodged wax was very long tubular shape. The family member said that after that process, Resident #93 complained the TV was too loud. The family member said that when he visited the resident, he requested that nursing follow-up on cleaning out her wax. When asked if he also requested that prior to , the family member explained that he initially requested it approximately 2 weeks ago. He did not remember which nurse he spoke to. An interview was conducted at 11:40 AM with Staff B, who is a Licensed Practical Nurse and the Unit Manager. When asked if there was a plan in place to address the family member's two requests to have Resident #93's earwax cleaned out, Staff B said she was not aware of those requests. She searched through Resident #93's medical record and she did not see any notes about the request. She did not find any documentation or orders to follow-up on earwax removal for Resident #93. (D) Based on observation, record review and interview the facility failed to ensure care and services for an for 1 of 3 residents as evidence by a failure to have an anchor for a , and failure to follow the physicians order by notifying the physician of the change in the color of the for Resident #128. The findings included: Observations of Resident #123 on and at 1:00 PM at 10:29 AM revealed a bag STATE FORM

N0201 SS = D Continued from page 14 containing was noted to be dark orange in color. The water cup at the bed was observed to be full. Observations of Resident #123 on at 9:00 AM revealed a bag containing was noted to be dark brown in color. There was no anchor attached to the tubing. The water cup at the bed was observed to be full. Review of the electronic record for Resident #128 revealed that she was admitted to the facility on with a diagnosis to include and of the physician's orders revealed and A review of Monitor Q (appearance (color, consistency, changes in odor, etc.) and/or no output, every shift. Notify the physician of related to use of to a diagnosis of . The Interventions included encourage and assist resident with fluid intake as tolerated; Monitor for signs and symptoms of bacteriuria; tinged cloudiness, no output, deepening of color, increased , increased temp. foul smelling , chills, change in behavior, change in eating patterns. Report abnormalities to nurse/MD as needed; and Teach resident or caregiver on use of importance of adequate fluids, signs and symptoms of and such as such as cloudy and output, and foul-smelling Further record review revealed the resident has related to diagnosis of . thought processes During an interview on at 9:30 AM with Staff I, LPN (Licensed Practical Nurse) the surveyor asked the nurse to come to the resident's room and to look at her The nurse confirmed that the resident did not have an anchor. The surveyor then asked what the process is if is dark in color. She stated the resident needs hydration, she would offer her water and she would reach out to the physician. The surveyor then asked if she had reached out to the physician since the resident's has been like this since Monday and today (Thursday), she replied no, but I will. During an interview on at 10:41 AM with the Director of Nursing (DON) he stated ( he called the ) physician and he ordered fluids 1 liter (1,000 ml) to run at 100/ml (milliliters) for 1 hour for 1 liter. /CMP (Complete. N0201

N0201 SS = D Continued from page 15 Count/Comprehensive with Panel) and He stated the nurse should have called the physician, there is an order to do so. The DON added that an anchor should always be on, unless the resident refuses it or doesn't want it. E) Based on policy review, observation, interview and record review, the facility failed to ensure appropriate care and services for use for 2 of 2 sampled residents as evidenced for failure to follow physicians orders for administration and parameters, and to maintain sanitary conditions of the tubing for Resident #1, and to ensure a clean concentrator filter and change per request for Resident #1. The findings included: Review of the policy, " Administration" dated documented in part, "1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for administration." 1) Review of the record revealed Resident #1 was admitted to the facility on with diagnoses to include acute supply to the ) and failure with (a lack of ) (a progressive causing sever breathing difficulties). Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a ( ) score of 14, on a 0 to 15 scale, indicating the resident was This same MDS also documented the resident used supplemental . Review of the physician orders revealed an order dated for continuous at 2 liters per minute for Resident #1 for a diagnosis of . Further review of the orders and care plans lacked any instructions for cleaning the concentrator filter. During an interview and observation on at 12:35 PM, Resident #1 stated he had been asking for new tubing as the one he had was not working well. Observation of the tubing revealed a kink in the tubing as it was bent down near where it connected to the concentrator. The was running at 5 liters per minute. When asked if this was the correct rate of administration, the resident stated it was. Observation Florida Department of Health PRINTED: 04/20/2026 03/12/2026 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0201 SS = D Continued from page 16 of the filter revealed it was gray and dust laden. Photographic evidence obtained. During an observation on at 3:40 PM, the .. filter and tubing remained the same. During an interview on at 4:16 PM, when asked about the process for .. maintenance regarding changing the tubing and cleaning the filters, Staff B, Licensed Practical Nurse (LPN) First Floor Unit Manager, stated the night shift does both on Wednesdays. The Unit Manager observed the resident's concentration filter and bent .. tubing and agreed with the findings. 2) Review of the record revealed Resident #41 was admitted to the facility on with diagnoses including and . Review of the current Minimum Data Set (MDS) assessment dated documented the resident had a ( ) score of 15, on a 0 to 15 scale, indicating intact cognition. Review of the Physicians Orders for Resident #41 revealed the following orders both dated resident to use : NCVMask. Encourage and assist Canula as needed for .. at 2 Liters/min via .. saturation less than 92% as needed, and .. tubing change: Change tubing/mask/bag Q week and as needed (PRN) every night shift every Wednesday and as needed. During observations on at 10:49 AM, Resident #41 was in bed with the .. 2 Liters, and the concentrator running at was located on the floor. Resident #41 had his breakfast tray in front of him on his bedside table. During another observation at 1:25 PM, Resident #41 was sitting upright in bed with his lunch tray on his bedside table and his tubing was located on the floor. Photographic Evidence Obtained. Resident #41 pushed his call bell and Staff G; Restorative Aide came in and after surveyor intervention Staff G noticed that the was located on the floor while the machine was running. Staff G picked up the tubing off the floor and running the tubing off the floor and hung the tubing on the drawer of the bedside table instead of disposing of it. Staff G went to get Staff F, Licensed Practical Nurse (LPN) to let her know that Resident #41 did not have his .. on. Staff G failed to inform Staff F that the .. tubing was found on the floor. Staff F came into Resident #41's room and attempt to reinsert the tubing into Resident #41's and was advised by the surveyor that the tubing had been on the floor and Florida Department of Health LUXE AT WELLINGTON REHABILITATION CENTER THE 10330 NUVISTA AVENUE, WELLINGTON, Florida, 33414

N0201 SS = D Continued from page 17 Staff F stated that she found it on hanging on the drawer of the bedside table and was not informed that it should have been on the floor. Staff F was asked if she should take Resident #41's .. saturation since he had not had his .. on for at least 2 ½ hours. Resident #41 stated to Staff F that he is now on room air and does not need .. Staff F retrieved the saturation level was 98 percent. Staff F advised Resident #41 that he had a Physician's order for and encouraged him to put the new tubing on and that she would contact his doctor to see if Resident #41 still needs .. and Resident #41 gave in and agreed to let Staff F assist him with putting the in his Observations on at 08:55 AM, and 3:20 PM, at 9:58 AM, and on at 10:23 AM, and the .. concentrator was running at 2 Liters. Review of Vitals- .. Saturation revealed that Resident #41's Saturation was above 92 percent 22 out of 23 documented assessments while on room air 10 times and while on .. at 2 Liters 12 times. An interview was conducted on at 12:35 PM with Staff F (LPN) who was asked about the .. order for Resident #41. She stated he was on 2 liters of continuous .. and then reviewed the .. order and stated that she was wrong the order was for 2 liters of .. if residents .. saturation was below 92 percent. She was asked what should have occurred on when Resident #41's saturation was 98 percent. Staff F stated that she shouldn't have put the .. on Resident #41 since his .. was at 98 percent. She then confirmed that the .. order for Resident #41 had never been for continuous .. . An interview was conducted on at 1:25 PM with Staff G, restorative aide, who confirmed that he found the .. on the floor in Resident #41's room and had forgot to tell Staff F that it was on the floor. He stated that he should have just thrown out the tubing and not hung it on the bedside table drawer. Class III STATE FORM