Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jupiter Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food handling and sanitation, including improper storage of raw eggs above pasteurized eggs, failure to store sanitized utensils correctly, use of chipped plates, and staff not performing required hand hygiene before donning gloves or after leaving food preparation areas. Additionally, a knife used for food prep was not properly cleaned and sanitized before being stored.
Surveyors found that the facility failed to provide adequate housekeeping and linen services, resulting in unclean dining and resident areas, persistent odors, and a lack of incontinence pads and clean linens. Staff and residents reported insufficient cleaning, especially on weekends, and observations confirmed soiled and threadbare linens, debris, and foul odors in multiple areas. Facility leadership acknowledged the deficiencies during the survey.
A resident with mild cognitive impairment reported missing blankets to multiple staff members over nearly two weeks without timely response or resolution. Despite facility policy requiring prompt grievance handling, staff failed to document or address the complaint until the issue was escalated, and the grievance form remained incomplete.
Surveyors identified that two residents received inaccurate MDS assessments: one resident's assessment incorrectly documented a contraindication for a Gradual Dose Reduction of an antipsychotic, despite no supporting evidence in the record, and another resident's assessment listed a weight that did not match the most recent entry in the electronic medical record. The MDS Coordinator and RD confirmed these discrepancies during interviews.
Surveyors identified that two residents did not have care plans addressing their specific clinical needs: one with PTSD and severe cognitive impairment lacked a care plan for PTSD, and another with diabetes and an insulin order had no care plan for diabetes management or insulin use. Staff interviews revealed gaps in awareness and understanding of these conditions and their management.
The facility did not update care plans for two residents after changes in their diet and medication orders. One resident's care plan did not match the physician's prescribed diet, and another resident's care plan listed anti-anxiety medication use despite no current order for the medication.
A resident with severe cognitive impairment developed a skin rash and received a one-time dose of Permethrin cream as ordered by the NP, with a plan for reassessment. The resident continued to experience itching and rash in multiple areas, but no further treatment or timely follow-up was provided, and staff were unaware of additional interventions or dermatology consultations.
A resident with severe cognitive impairment developed a right heel pressure ulcer, and staff failed to follow physician orders for wound care. Observations showed the foam dressing was not changed as ordered, was partially detached and exposing the wound, and had not been replaced for several days despite documentation indicating otherwise. The resident experienced discomfort, and the dressing was found to have foul odor and drainage before being changed by an LPN.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not provide fortified foods or prescribed meals to three residents with nutritional concerns, including those who were underweight or had experienced weight loss. Despite dietary orders and care plans specifying the need for fortified foods at each meal, observations and interviews confirmed that these items were not consistently provided. One resident also reported not receiving the correct meal as ordered, and staff acknowledged the discrepancies.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
A resident with multiple psychiatric diagnoses was prescribed Divalproex Sodium, and a physician ordered a valproic acid level to be measured. The clinical record lacked documentation of the test result, and the DON confirmed the absence of the result after reviewing records and contacting the lab.
The facility did not consistently follow infection control protocols, including TBP and EBP, for three residents. One resident on contact isolation for possible C. diff was repeatedly seen outside their room, another resident on EBP for dialysis and a central line lacked proper signage after a room change, and a third resident with an MDRO and wound received personal care from a CNA who did not wear a gown as required. Staff interviews revealed gaps in knowledge and adherence to PPE protocols.
Surveyors observed live roaches in multiple kitchen and food service areas, including on a table near the conveyor toaster and behind a cart with trays and single service items. Numerous roaches in all stages of life were present, and attempts to contact the pest control company went unanswered.
The nursing staff failed to follow prescribed medication parameters for two residents. One resident with diabetes received insulin despite blood sugar levels below the threshold, while another with hypertension was given medication despite low blood pressure readings. The DON confirmed these discrepancies.
The facility failed to coordinate medication administration with dialysis services for two residents, resulting in medication omissions and incomplete dialysis communication records. One resident did not receive several prescribed medications due to being in dialysis, and the facility did not document pre and post-dialysis assessments. Another resident's blood pressure medications were held on dialysis days without provider orders, as confirmed by the Risk Manager. These deficiencies highlight a lack of coordination and documentation in ensuring appropriate care during dialysis.
A facility failed to ensure nurses followed physician's orders for medication administration. A resident received Midodrine HCl despite having a systolic blood pressure above the prescribed threshold, and insulin was administered when blood sugar levels were below the specified threshold. The Risk Manager confirmed these findings, indicating a lack of adherence to medication administration policies.
Deficient Food Handling and Sanitation Practices Identified
Penalty
Summary
The facility failed to ensure that food was prepared, stored, and served in a sanitary manner according to professional standards. During an initial kitchen tour, raw shell eggs were found stored directly above liquid pasteurized eggs in the walk-in cooler, creating a risk of cross-contamination. Additionally, cleaned and sanitized utensils were not stored inverted as required. These issues were acknowledged by the Certified Dietary Manager (CDM) at the time of observation. Further observations revealed that staff did not consistently perform proper hand hygiene before donning gloves, as required by facility policy. One cook was observed taking gloves without washing hands before returning to food service, and a dietary aide also failed to perform hand hygiene after leaving and re-entering the food preparation area before handling gloves and parchment paper. The kitchen also contained several chipped plates that could potentially cause skin tears, and a knife used for food preparation was only rinsed, not properly cleaned and sanitized, before being placed back on a magnetic strip. These deficiencies were acknowledged by the CDM and the staff involved.
Failure to Maintain Clean, Sanitary, and Homelike Environment Due to Housekeeping and Linen Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's maintenance, housekeeping, and linen services, resulting in an environment that was not clean, sanitary, or homelike. In the main dining room, a plastic table with accumulated food residue and debris was found, and trash containers were not emptied in a timely manner, leading to foul odors. Tablecloths on several tables were stained with food residue. The Food Services Director and Certified Dietary Manager confirmed these issues, noting that housekeeping was responsible for trash removal and kitchen staff for changing linens. In resident rooms, surveyors found soiled gowns left in showers, debris on floors, and strong urine odors, particularly in a shared room with four beds. Two residents in this room were totally dependent on staff for care, and one was observed lying on a mattress with a large wet spot and a persistent urine odor. Staff reported a lack of incontinence pads, resulting in urine soaking through sheets and into mattresses. Threadbare sheets were also observed in use. Laundry carts on all units lacked incontinence pads, and only a few were found in the laundry area. The Housekeeping Director acknowledged that pads should have been available but cited being pulled in different directions as a reason for the shortage. Interviews with residents and staff revealed concerns about reduced housekeeping staff on weekends, leading to delays and lower cleaning standards. The Housekeeping and Maintenance Directors were unsure about the replacement of odorous mattresses and agreed with the surveyors' findings upon inspection. The Director of Nursing stated that cloth incontinence pads were intended for all beds, but they were not consistently available. Photographic evidence was obtained to document the use of threadbare linens and the lack of incontinence pads.
Failure to Timely Address Resident Grievance Regarding Missing Personal Items
Penalty
Summary
Staff failed to respond in a timely manner to a resident's grievance regarding missing blankets, despite the resident voicing her concerns to multiple staff members over the course of nearly two weeks. The resident, who had mild cognitive impairment as indicated by a BIMS score of 11, reported the missing blankets to several staff, including at the nurses' station, but no action was taken initially. The resident eventually spoke to the housekeeping director after repeated complaints to other staff members. Facility policy required grievances to be documented and addressed promptly, with forms available at several locations. However, the grievance form for this incident was not completed in full and lacked documentation of follow-up or resolution. Interviews with the social worker and housekeeping director confirmed delays in addressing the complaint, and the resident's family was only contacted after the grievance was formally recognized. The resident's inventory did not list the missing blanket, and the issue remained unresolved at the time of the report.
Inaccurate MDS Assessments for Antipsychotic Use and Resident Weights
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly documented that a Gradual Dose Reduction (GDR) for an antipsychotic medication was both attempted and contraindicated on the same date. Record review showed that the resident had been on Risperdal, an antipsychotic, for a neurological condition (Huntington's disease) since 2022, with no change in dosage and no documented contraindication for a GDR. The MDS Coordinator confirmed that the documentation of a contraindication was incorrect and that there had been no recent changes to the antipsychotic medication. Additionally, the discontinuation of an antianxiety medication was incorrectly associated with the antipsychotic medication in the assessment. For another resident, the MDS assessment inaccurately recorded the resident's weight. The assessment listed a weight of 134 pounds, while the most current weight in the electronic medical record prior to the assessment date was 132 pounds. The Registered Dietician (RD) stated that she obtains weights directly from the electronic medical record and uses the most recent weight before the assessment date. Upon review, the RD acknowledged the inconsistency between the documented weight in the MDS and the electronic medical record.
Failure to Develop and Implement Care Plans for PTSD and Diabetes Management
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents with specific clinical needs. For one resident with severe cognitive impairment and a diagnosis of Post Traumatic Stress Disorder (PTSD), there was no care plan in place to address PTSD, despite documentation of the diagnosis in the resident's assessment. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD, its triggers, and appropriate interventions. The resident's Power of Attorney identified specific triggers such as loud noises and fireworks, but this information was not incorporated into a care plan, and staff were either unaware of the PTSD diagnosis or unclear about how to address it. In a separate case, another resident with a diagnosis of diabetes and an active order for insulin did not have a care plan addressing diabetes management or insulin administration. The interdisciplinary team reviewed care plans but failed to develop one for the resident's diabetes or insulin use. The MDS Coordinator confirmed the absence of an active care plan for these needs. These omissions were identified through record review and staff interviews during the survey process.
Failure to Update Care Plans Following Changes in Diet and Medication Orders
Penalty
Summary
The facility failed to update and maintain accurate care plans for two residents following changes in their clinical status and physician orders. For one resident, the care plan did not reflect the current prescribed diet, as the physician ordered a regular, pureed texture with nectar thickened fluids, but the care plan listed a regular, mechanically altered ground texture with nectar thickened liquids. For another resident with an anxiety disorder, the care plan continued to indicate the use of anti-anxiety medication, even though there was no current physician order for such medication. The MDS Coordinator confirmed that the care plan was not updated to reflect the resident's current medication status.
Failure to Provide Ongoing Treatment and Follow-Up for Persistent Skin Rash
Penalty
Summary
A resident with severe cognitive impairment was admitted to the facility and developed a skin rash. The nurse practitioner (NP) assessed the resident and prescribed a one-time dose of Permethrin 5% cream for suspected scabies, with a plan to reevaluate the rash after treatment. However, there was no documented follow-up or reassessment by the NP as planned, and no additional treatments for itching were ordered. The resident continued to experience symptoms, including itching and the spread of the rash to multiple areas, as observed during interviews and skin assessments. Despite the resident's ongoing symptoms and reports of discomfort, staff interviews and record reviews confirmed that no further interventions or dermatology consultations were initiated in a timely manner. The unit manager and medical director were unaware of any additional treatment orders or scheduled dermatology visits, and the resident did not receive further care for the persistent rash. This lack of follow-up and failure to provide appropriate ongoing treatment according to the resident's needs and the NP's plan resulted in the resident remaining symptomatic.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Staff failed to follow physician orders for the treatment of a facility-acquired pressure ulcer for one resident with severe cognitive impairment. The resident had a new right achilles (heel) pressure ulcer, and physician orders directed staff to cleanse the wound with normal saline, apply skin prep to the necrotic area, and cover with a foam dressing every day shift on Monday, Wednesday, and Friday, as well as as needed for saturation or dislodgment. Observations revealed that the foam dressing was partially hanging off and exposing the wound on multiple occasions, with photographic evidence obtained. The dressing was also noted to be dated several days prior, indicating it had not been changed as ordered. Review of the Treatment Administration Record (TAR) showed that an LPN had signed off on performing the wound care treatment on specific dates, but direct observation contradicted these records. The resident was observed experiencing discomfort and was found with a foul-smelling dressing with dark brownish drainage and eschar present. The dressing was removed by staff only after the resident indicated discomfort, and it was confirmed that the dressing had not been changed according to the physician's orders.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Prescribed Fortified Foods and Meals to Residents with Nutritional Concerns
Penalty
Summary
The facility failed to provide adequate nutrition to residents with identified nutritional concerns, as evidenced by the lack of fortified foods and missed prescribed meals for three residents. For two residents who were underweight or at risk for malnutrition, meal tickets and care plans specified the need for fortified foods such as fortified cereal and potatoes with all meals. However, direct observations on multiple occasions revealed that these fortified foods were not included on their trays, despite clear dietary orders and documentation. Staff confirmed that the residents did not receive the required fortified foods, and photographic evidence supported these findings. One resident with a diagnosis of malnutrition and a low BMI experienced significant weight loss over a short period. This resident reported dissatisfaction with the quality and temperature of the food and specifically noted not receiving the prescribed meal (spaghetti with meat sauce), instead receiving only the meat sauce. The registered dietitian confirmed that the meal provided did not match the meal ticket or the resident's dietary order. The resident's care plan had been updated to address his risk for malnutrition, but the prescribed interventions were not consistently implemented. Another resident with a history of Alzheimer's disease, anorexia nervosa, and dysphagia was also observed not receiving fortified foods as ordered. This resident had experienced a notable weight loss over six months, and the care plan included specific interventions to provide fortified foods at each meal. Despite these orders, observations showed that the resident's trays did not include the required fortified items, and the meal tickets continued to indicate the need for fortified foods. These failures were acknowledged by facility management and the registered dietitian during interviews.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Obtain Ordered Valproic Acid Level for Resident on Divalproex
Penalty
Summary
The facility failed to obtain a required laboratory test for one resident who was prescribed Divalproex Sodium for a mood disorder. Upon admission, the resident had diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder, and a physician's order was written for a valproic acid level to be measured on a specified date. Review of the clinical record showed no documented evidence that the valproic acid test was performed or that results were available. During an interview, the Director of Nursing confirmed the absence of the test result after reviewing the resident's records and contacting the laboratory, which also did not have the result.
Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices for three residents by not adhering to Transmission-Based Precautions (TBP), Enhanced Barrier Precautions (EBP), and appropriate use of Personal Protective Equipment (PPE) during direct care. For one resident with a recent diagnosis of a left thigh fracture and multiple episodes of loose stools, a physician ordered contact isolation to rule out Clostridium difficile (C. diff) infection. Despite this, the resident was observed multiple times in the hallway outside of their private room while still pending lab results for C. diff, contrary to the facility's TBP policy that requires residents on isolation to remain in their rooms except for medically necessary care. Another resident with end-stage kidney disease requiring dialysis and a central line was placed on EBP per physician order, with care plans specifying the use of gown and gloves during high-contact care activities. However, after the resident changed rooms, EBP signage was not posted on the new room door as required, potentially leading to lapses in staff adherence to EBP protocols. Observations confirmed the absence of EBP signage on the door during multiple checks. A third resident, who was treated for a multi-drug resistant organism (MDRO) of the urine and had an open wound, was on contact precautions followed by EBP. During direct care, a CNA was observed providing personal care and changing an adult brief while wearing gloves but not donning a gown, both when the resident was on contact precautions and later on EBP. The CNA was unfamiliar with the meaning of EBP, contact precautions, and the facility's system for identifying residents on precautions, as confirmed during interviews. The Infection Preventionist acknowledged that a gown should have been worn during these care activities.
Failure to Maintain Effective Pest Control in Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by direct observations of live roaches in multiple areas of the kitchen. During a kitchen tour with the Food Service Director/Certified Dietary Manager, two live mature roaches were seen on a table near the conveyor toaster in the hot holding area. Additionally, in the food service area where staff collect plates and prepare them for distribution, numerous live roaches in various stages of life were observed behind a cart containing trays and single service items such as sugar packets, condiments, and tea bags. The surveyor also attempted to contact the pest control company servicing the facility but did not receive a response. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Follow Prescribed Medication Parameters
Penalty
Summary
The nursing staff failed to adhere to prescribed parameters for administering medications to two residents, leading to deficiencies in care. Resident #5, who was admitted with a diagnosis of Diabetes Mellitus with Hyperglycemia, was prescribed Insulin Lispro to be administered before meals, with instructions to hold the dose if blood glucose levels were below 150. Despite this, the resident received insulin on multiple occasions when their blood sugar levels were below the specified threshold, with readings ranging from 110 to 123. Similarly, Resident #1, who was admitted with Congestive Heart Failure and Hypertension, was prescribed Entresto with instructions to hold the medication if systolic blood pressure was below 110. However, the medication was administered on two occasions when the resident's blood pressure was recorded at 106/60 and 92/58, respectively. The Director of Nursing confirmed that the medications were given despite the prescribed parameters, indicating a failure in following medical orders.
Failure to Coordinate Medication Administration with Dialysis Services
Penalty
Summary
The facility failed to coordinate medication administration times with dialysis services for two residents, leading to medication omissions. For one resident, the Medication Administration Records (MAR) indicated that several prescribed medications were not administered on specific dates because the resident was in dialysis. The facility did not ensure that medications were given as prescribed, which was confirmed by the Risk Manager during an interview. Additionally, the facility did not complete dialysis communication records to validate continuity of care, as evidenced by missing documentation of pre and post-dialysis assessments, including vital signs, condition of the access site, and signs of infection. For another resident, the facility failed to administer prescribed blood pressure medications on dialysis days without provider orders to hold them. The MAR showed that medications were held on specific dates with the reason noted as the resident having dialysis. The Risk Manager confirmed that the nurse likely held the medications due to concerns about blood pressure dropping during dialysis, but there were no orders to support this action. This lack of coordination and documentation led to deficiencies in ensuring the residents received appropriate care during dialysis.
Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated competency in following physician's orders for medication administration and documentation for a resident. The facility's policy on administering medications, last revised in April 2019, outlines that medications should be administered safely, timely, and as prescribed, with specific guidelines for checking and verifying medication details before administration. However, the clinical record review revealed that the resident received Midodrine HCl despite having a systolic blood pressure above the prescribed threshold on multiple occasions. Additionally, the medication was withheld when the blood pressure was below the threshold, indicating a failure to adhere to the physician's orders. Furthermore, the resident was administered Insulin Lispro despite blood sugar levels being below the threshold specified in the physician's order. The Medication Administration Records showed multiple instances where insulin was given when the blood sugar was below 200, contrary to the physician's directive. An interview with the Risk Manager confirmed these findings and highlighted the need for clarification in the insulin order for proper documentation. These actions demonstrate a lack of adherence to the facility's medication administration policy and physician's orders, leading to the identified deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jupiter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luxe At Jupiter Rehabilitation Center (the) | 3.7 mi | ★★★★★ | 2 | 0 |
| Nursing Center At La Posada, The | 6.4 mi | ★★★★★ | 0 | 0 |
| Gardens Court | 6.9 mi | ★★★★★ | 6 | 0 |
| Waterford, The | 6.9 mi | ★★★★★ | 0 | 0 |
| Prosper Health And Rehabilitation Center | 7.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.