Two of the four compartments on the facility's steam table had stopped working, forcing dietary staff to improvise with boiling water just to use the equipment. The maintenance department told kitchen staff the steam table couldn't be repaired and would need replacement, but no timeline was provided.
When inspectors tested meal temperatures in July, they found garlic pepper pork loin with gravy at 110 degrees, zucchini and tomatoes at 100 degrees, and corn at 110 degrees. The dietary manager confirmed the food was lukewarm and not at an appetizing temperature.
The facility's own policy requires hot food to be served between 110 and 120 degrees Fahrenheit for palatability and food safety. But residents had been receiving meals below those standards for months.
Resident 53, who has been at the facility since January with bilateral knee arthritis and high blood pressure, told inspectors on July 14 that food had been served cold at times. A nursing aide who started in April confirmed that residents had complained about cold food throughout her tenure.
Another aide explained that Resident 53 and other residents had complained about cold food for several months. Yet when inspectors called the facility's registered dietitian on July 17, she said she wasn't aware residents were complaining about cold food.
The administrator, who had been in her position for just three weeks, acknowledged she was made aware recently that residents had been complaining about cold food and that the steam table wasn't working properly. She said she expected all food to be delivered at an appetizing temperature.
Kitchen observations revealed additional food safety problems beyond temperature control. Staff weren't covering plates as they prepared meal trays, leaving up to six racks of uncovered food sitting on carts. The first tray cart left the kitchen at 12:05 PM with no plate covers, and the last cart containing four trays left at 1:14 PM still uncovered.
By the time a test tray reached inspectors in the conference room at 1:18 PM, the food was lukewarm to taste.
Food contamination issues compounded the temperature problems. During a July 14 kitchen inspection, staff found three green bell peppers with soft, pliable spots and areas of white biological growth. Fifteen containers of seasonings sat open and exposed, violating the facility's food storage policy requiring dry products to be kept in tightly sealed containers.
The cook acknowledged the overly ripe bell peppers and exposed seasonings but said she was unaware the produce had spoiled. She and the dietary manager were supposed to be responsible for maintaining food quality in the kitchen.
The next day, inspectors watched a cook pick up a glove from the floor and place it directly on a food preparation table where pureed tomatoes and sandwiches were being prepared. When questioned, the cook acknowledged she knew food was being prepared on the table but didn't want to put the dirty glove back with clean ones. She confirmed the floor was considered dirty and the glove should have been discarded.
The dietary manager was aware of all these issues, including the spoiled peppers, exposed seasonings, and the glove incident. She said it was her responsibility and the cook's to ensure spoiled foods were discarded and seasonings remained closed. She expected items picked up off the floor to be discarded appropriately.
Beyond kitchen operations, the facility failed to accurately report staffing levels to federal regulators. The business office manager discovered after attending a company training in May that several employees who work multiple jobs weren't being coded correctly when they worked direct care shifts on weekends.
This coding error made it appear the facility had no nursing staff working on certain weekend days in the second quarter of 2024, including February 17-18, March 9-10, and March 30-31. The facility triggered federal alerts for excessively low weekend staffing and received a one-star staffing rating as a result.
A registered nurse who normally manages the transitional care unit worked floor shifts on February 17, March 9, and March 10 but wasn't coded as providing direct nursing care. Two certified nursing aides whose primary jobs were transportation worked as CNAs on March 2 but weren't properly coded. A licensed practical nurse from medical records worked direct care shifts on February 17-18 and March 10 without proper coding.
The director of nursing said she was notified on June 3 that the facility had triggered low staffing alerts because of inaccurate coding. She and the business office manager would now have to manually code staff who work weekends in positions different from their primary jobs.
The administrator confirmed the facility triggered federal alerts for low weekend staffing and maintains a one-star rating. She said the director of nursing and business office manager would manually enter correct codes to fix the problem, though she had only been administrator for three weeks when inspectors arrived.
Resident 53, whose mental status assessment showed cognitive function was intact, experienced the daily consequences of these systemic failures. After six months at the facility, this resident continued receiving cold meals while kitchen staff worked around broken equipment and handled contaminated food.
The facility's infection prevention policy aims to decrease infection risks and maintain compliance with federal regulations. Yet inspectors found staff placing floor-contaminated gloves on food preparation surfaces and storing produce with visible mold growth.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunplex Sub-acute Center from 2024-07-17 including all violations, facility responses, and corrective action plans.