Sunplex Sub-Acute Center

In the surveyor’s words

From the most serious findings on record at Sunplex Sub-Acute Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF838Oct 28, 2025

  Based 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… […]

• Immediate jeopardy, widespreadF865Oct 28, 2025

  Based 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. […]

• Immediate jeopardy, widespreadF880Oct 28, 2025

  Based 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.The facility's failure to identify the presence of an outbreak, initiate droplet precautions, post appropriate signage, notify the local health department, provide staff and family education regarding the outbreak, ensure the Infection Preventionist and clinical leadership verified… […]

• Immediate jeopardy, patternF600Oct 28, 2025

  Based 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. […]

• Immediate jeopardy, patternF725Oct 28, 2025

  Based 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.The situation was… […]