Sunplex Sub-Acute Center

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to protect Resident #1 from misappropriation of property when a Certified Nurse Aide (CNA) removed the resident's debit card without permission and used it at multiple locations for unauthorized purchases for one (1) of four (4) residents sampled. Resident #1Findings include: A review of the facility's ABUSE AND NEGLECT POLICY AND PROCEDURE revised, 10/21/25, revealed, .Policy: To provide a safe environment for all residents free of abuse. Procedure. II. Types of Abuse.7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the facility assessment contained required details regarding staffing needs by shift and by unit and failed to maintain an actionable contingency plan for staffing emergencies for (59) of (59) residents in the facility during the influenza outbreak from 10/8/25 through 10/12/25. The facility's failure of not specifying in the facility assessment the number of licensed nurses and Certified Nurse Aides (CNAs) needed per shift and per unit to meet resident needs and the contingency plan not containing clear procedures for securing coverage during emergencies or staff call-offs, resulted in the facility being unprepared for staff absences during the influenza outbreak, which placed all residents at risk for serious illness, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control and staffing during an influenza (flu) outbreak for 59 of 59 residents residing in the facility from 10/8/25 through 10/12/25. The facility's failure to use its QAPI program to evaluate and address the lack of outbreak recognition including failure to initiate droplet precautions, failure to notify the local health department, failure to ensure antiviral medications were administered as prescribed, and failure to monitor staff illness and infection control compliance resulted in continued exposure and spread of influenza within the facility. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices to prevent and contain the spread of influenza (flu) when three (3) residents (Residents #1, #53, and #63) tested positive between 10/8/25 and 10/12/25 for (59) of (59) residents in the facility. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care (a high contact care activity) for Resident #49. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when licensed nursing staff failed to administer prescribed medications, failed to notify physicians of missed medications, and failed to ensure residents received appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak for five (5) of (5) residents reviewed for medication administration, Residents #12, #28, #36, #53, and #100. This had the potential to affect all 29 residents on the [NAME] Unit. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide sufficient licensed-nurse and nurse aide coverage to meet resident needs. Specifically, the facility failed to ensure adequate licensed nurse coverage during an influenza (flu) outbreak for one (1) of two (2) resident care units (the [NAME] Unit) and failed to ensure sufficient nurse aide staffing to provide scheduled showers for three (3) of (17) sampled residents (Residents #24, #54, and #58). The facility's failure to ensure sufficient licensed-nurse coverage resulted in missed medications and lack of resident monitoring on the [NAME] Unit, which placed all 29 residents on the [NAME] Unit at risk for serious illness, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food items were stored and maintained in a safe and sanitary manner as evidenced by not discarding expired products and spoiled food and not refrigerating items according to manufacturer's instructions for one (1) of four (4) survey days.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a safe, clean, and comfortable environment when a resident was left with soiled linens for multiple days for one (1) of 17 sampled residents, Resident #2.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with an indwelling catheter (Resident #49) and failed to implement care plan interventions related to baths/showers as scheduled (Resident #54 and #58) for three (3) of 17 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice, as evidenced by nursing staff did not notify the physician or attempt to obtain medications from an alternate pharmacy source when ordered medications were unavailable for one (1) of five (5) residents observed for medication administration, Resident #9. Findings Include:A review of the facility's policy, Medication Administration - General Guidelines, dated 8/25/14, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that residents who were dependent upon staff for activities of daily living (ADL) care received assistance with bathing and personal hygiene as scheduled and in accordance with their needs and preferences for three (3) of (17) sampled residents (Residents #24, #54, and #58).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration for one (1) of (17) sampled residents (Resident #2).

Inspectors wroteBased on staff interview and record review, the facility failed to accurately document a resident's weight in the medical record for one (1) of 17 sampled residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure food items were stored and maintained in a safe and sanitary manner by not discarding expired products and spoiled food, and not refrigerating items according to manufacturer's instructions and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of (13) deficiencies cited. F812. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an elopement for one (1) of four (4) sampled residents, Resident #1. On 9/17/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of six (6), and was identified by the facility as an elopement risk, was assisted out of the front door by a Dietary Aide (DA) who thought she was a visitor. She remained outside the facility for approximately 35 minutes, during which the DA left the facility parking lot at approximately 8:50 PM. Resident #1 was found at 9:05 PM knocking on the front entrance door. The facility's failure to provide supervision placed Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure a resident's safety during a bed bath, in which Resident #2 fell from the bed to the floor, sustaining fractures to her bilateral lower extremities for one (1) of four (4) residents reviewed for falls. Findings Include: A review of the facility's policy titled Accidents and Incidents, undated, revealed It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible . A record review of the facility's investigation of Resident #2's fall with fractures revealed that on 12/21/24 at approximately 10:45 AM, Certified Nurse Assistant (CNA)# 1 provided care and a bath to Resident #2 while turning her in the bed on her left side. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively addressed and prevented the recurrence of resident accidents. This failure resulted in a resident sustaining bilateral fractures, despite a prior citation for F689 on 10/3/24, which indicates the facility did not sustain systemic corrective actions to prevent the recurrence for one (1) of four (4) sampled residents. Resident #2. Findings Include: A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program dated 10/22, revealed, .The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect a vulnerable resident when Certified Nursing Aide (CNA) #1 and CNA #2 did not safely position Resident #1 in the bed allowing the resident to fall to the floor for one (1) of four (4) residents reviewed for falls. (Resident #1) Findings Include: A review of the facility's undated policy titled Accidents and Incidents revealed: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and that residents receive supervision and assistive devices to prevent accidents whenever possible . A record review of the facility's investigation revealed on 9/19/24, around 8:05 AM, the Director of Nursing (DON) notified the Administrator of an allegation of abuse between Resident #1 and CNA #1. [...]

Inspectors wroteBased on observations, interviews, record reviews, test tray evaluation, and facility policy review, the facility failed to ensure the resident's food was at an appetizing temperature for one (1) of 16 sampled residents. (Resident #53). This has the potential to affect all residents receiving meals prepared by the facility's dietary department.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure spoiled food items were discarded, food items such as seasonings and spices were not open and exposed, and the food prep area was free from contamination for two (2) of two (2) kitchen observations. This has the potential to affect all residents receiving meals from the facility's dietary department.

Inspectors wroteBased on staff interviews and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ) (information on the staffing hours for the appropriate care of the residents) had been corrected before submitting to the Centers for Medicare and Medicaid Services (CMS) for the second Quarter of the 2024 Fiscal Year (January 1, 2024 - March 31, 2024) for one (1) of four (4) quarters.

Inspectors wroteBased on interviews, record reviews and facility policy review the facility failed to ensure a grievance of cold food by Resident Council members was resolved four (4) of six (6) months of Resident Council meetings reviewed.

Inspectors wroteBased on observations, record review, resident and staff interviews, and facility policy review, the facility failed to treat residents in a dignified manner, as evidenced by not providing meals consecutively to all residents who were seated at the same table for three (3) of 20 residents observed during a dining room observation.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, and the facility's policy, the facility failed to honor residents' request for an alternative menu as listed on the alternative menu for two (2) of two (2) residents sampled for choices.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure an unattended medication cart was secured and locked for one (1) of three (3) medication carts observed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent a significant medication error by applying a transdermal medication patch without removing the previously applied medication patch from the resident for one (1) of three (3) sampled residents.

Inspectors wroteBased on facility policy review, record review, and interviews the facility failed to notify Resident #1's primary physician following immediately of a change in status following an incident that required the resident to be transferred to the hospital for evaluation for one (1) of four (4) sampled residents. Resident #1. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, and care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van after being abandoned on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. [...]

Inspectors wroteBased on facility policy review, record review and interviews, the facility failed to ensure a resident was free from neglect for one (1) of four (4) sampled residents, Resident #1, as evidenced by on 9/15/23 at approximately 3:45 PM, after returning to the facility from a dialysis appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing medications, meals, hydration, and care and assessments, and expressing that she was anxious, hurting, and afraid and, I thought I was doomed. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions to ensure Resident #1 received care and services for monitoring after hemodialysis, significant medications, accu check and activities of daily living, for one (1) of four (4) resident care plans. Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility failed to implement the plan of care for Resident #1 when Resident #1 was left unattended, unsupervised without care or monitoring following transportation from hemodialysis treatment. Resident #1 was abandoned and restrained by seat belts in a wheelchair in the facility transport van. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide resident centered care and services in accordance with the resident's individualized care plan and professional standards of practice that met Resident #1's physical, mental, and psychosocial needs for one (1) of four (4) sampled residents, Resident #1, as evidenced by the facility abandoned Resident #1 on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. Resident #1 was left alone and unattended on the transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van and transferred the resident to their room in the facility. [...]

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to provide supervision for a resident who was left alone, abandoned, strapped in her wheelchair without monitoring on the facility transport van following a dialysis treatment for approximately 16 hours and 15 minutes for one (1) of four (4) Residents reviewed. Resident #1. The facility failed to remove the resident from the facility van following transportation from her hemodialysis treatment, abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's location from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Resident #1 received care and services following a hemodialysis treatment consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications after dialysis treatments for one (1) of four (4) residents reviewed, Resident #1 as evidenced by the facility failed to remove the resident from the facility van on 9/15/23 following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair restrained by the seatbelts in the facility van for sixteen (16) hours and fifteen (15) minutes without the staff's monitoring. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide adequate staffing to ensure the safety and the necessary care and services for one (1) of four (4) residents reviewed, Resident #1. The facility failed to identify the location of a resident when the resident failed to return to the facility unit following transportation from her hemodialysis treatment. This resulted in the facility abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to staff the facility sufficiently resulted in Resident #1 been left unattended in the facility van for over sixteen (16) hours. [...]

Inspectors wroteBased on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medication (anti-diabetic, anti-hypertension, bronchitis, and pain management medications) were administered to prevent discomfort or complications for one (1) of four (4) residents reviewed, Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. On 9/15/23 the facility failed to remove the resident from the facility van following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair in the facility van, unsupervised and without significant medications including insulin, respiratory and hypertensive medications for sixteen (16) hours and fifteen (15) minutes without the staff awareness. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident admitted to hospice services for one (1) of one (1) resident reviewed for hospice services. (Resident #45)

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure a baseline care plan included nursing healthcare information necessary to properly care for a newly admitted resident for one (1) of (18) sampled residents. Resident #250. Findings Include: Review of the facility's policy Care Plan -Baseline dated June 1, 2000, revealed Policy Statement It is the policy of this facility that an individualized baseline care plan be developed within 48 hours of admission that includes instructions needed to provide effective person center care of the resident that meets professional standards of quality care, maintained and/or updated, while a comprehensive care plan is developed . [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to develop a comprehensive care plan for three (3) of 18 residents reviewed for care plans. (Resident # 4, Resident #35, Resident #39) Findings Include: Review of the facility's policy, Care Plan Committee/Team dated 6/1/2000, revealed, Policy Statement It is the policy of this facility that the Care Planning Committee/Team develops a comprehensive, person-centered care plan for each resident within seven (7) days of completing the resident assessment (MDS) (Minimum Data Set). Care Plan to be completed no later than 21 days after admission .Procedures .3. Care Plan will be modified as needed to reflect residents current status and needs . [...]

Inspectors wroteBased on observation, interviews, record review a facility policy review reveal the facility failed to provide treatment consistent with professional standards of practice to an existing pressure injury after re-admission to the facility for one (1) of three (3) residents reviewed for pressure ulcers. Resident #4 Review of the facility's policy, admission and Readmission dated March 15, 2007, revealed, With each admission and readmission the admission Nursing Assessment should be done .The assessments included should be completed on all admission, readmissions .1. admission Nursing Assessment to be completed with each admission and readmission . Findings Include: During an interview on 6/27/22 at 12:56 PM with Resident #4 Mother revealed the resident returned to the facility from the local hospital on 6/20/22. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not labeled or dated with a Use-By date, and food items not discarded after the expiration date, for one (1) of two (2) kitchen observations. Findings Include: Review of the facility's policy Labeling and Dating for Safe Storage of Food with an expiration date of 3/6/2020 revealed, Objective: Participants will learn that labeling and dating are critical to promote food safety. The use of Use-By dates will be reviewed. All products should be dated upon receipt. All products should be dated when opened. Use Use-By dates on all food once opened and stored under refrigeration .Expiration dates supercede storage guide . [...]