Sunplex Sub-acute Center

F-F565:

Based on observations, interviews, and record reviews, 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.

A review of the facility's policy titled Food Temperatures, dated 03/19/20 revealed, Food should be served at

the proper temperature to ensure food safety and palatability. Procedure: . 8. Palatability of foods determines appropriate temperatures at bedside or tableside food. Generally, hot food is palatable between 110 degrees Fahrenheit (F) and 120 degrees Fahrenheit (F) .

On 07/14/24 at 11:24 AM, during an interview, Resident #53 complained the food had been served cold at times.

On 07/14/24 at 11:25 AM, during an interview with Certified Nurse Aide (CNA) #7, she explained she had been at the facility since April 2024, and residents had complained about the food being cold.

On 07/14/24 at 11:45 AM, during an interview with Dietary Department Cook/Staff #4, she revealed two (2) of

the four (4) compartments on the steam table did not work. The cook reported she poured boiling water into one of the inoperable compartments to use it. The cook revealed the Maintenance Department had been informed that the steam table could not be repaired. The cook stated she was informed that the steam table would have to be replaced.

On 07/15/24 at 11:35 AM, during an observation of the kitchen staff as they prepared trays, the staff were not covering plates as they prepared them. There were up to six (6) racks of trays on a cart with no lids on the plates.

At 11:39 AM on 07/15/24, during an observation of the steam table food temperatures, the scalloped corn was 170 degrees, garlic pepper pork loin was 160 degrees, and zucchini, tomatoes, and mushrooms were 170 degrees.

At 12:05 PM on 07/15/24, the first tray cart left the kitchen to go to the dining room. None of the dining room trays had a plate cover.

At 1:14 PM on 07/15/24, the last open tray cart containing four (4) trays left the kitchen to go to the hall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 255244 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255244 B. Wing 07/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunplex Sub-Acute Center 6520 Sunscope Drive Ocean Springs, MS 39564

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 On 07/15/24 at 1:18 PM, the test tray reached the State Agency (SA) in the conference room. The food temperatures revealed garlic pepper pork loin with gravy at 110 degrees, zucchini and tomatoes at 100 Level of Harm - Minimal harm or degrees, and corn at 110 degrees. The food was lukewarm to taste. The Dietary Manager confirmed the food potential for actual harm was lukewarm and not at an appetizing temperature.

Residents Affected - Many At 2:05 PM on 07/15/24, during an interview, CNA #5 explained Resident #53 and other residents had complained about the food being cold for several months.

On 07/17/24 at 10:50 AM, during a phone interview with the facility's Registered Dietitian, she explained she was not aware residents were complaining about the cold food.

On 07/17/24 at 2:15 PM, during an interview, the Administrator explained she was made aware recently that

the residents had been complaining about cold food and that the steam table was not working properly. She expected all food to be delivered to the residents at an appetizing temperature.

A record review of the Admission Record of Resident #53 revealed the facility admitted the resident on 01/24/24, with diagnoses that included Bilateral Primary Osteoarthritis of Knee and Essential Hypertension.

The significant change Minimum Data Set (MDS) for Resident #53, with an Assessment Reference Date (ARD) of 06/18/24, revealed a Brief Interview for Mental Status (MDS) score of 15, which indicated the resident was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 255244 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255244 B. Wing 07/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunplex Sub-Acute Center 6520 Sunscope Drive Ocean Springs, MS 39564

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48181

Residents Affected - Many Based 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.

Findings included:

A review of the facility's policy Food Storage, revised 07/11/2024, revealed, Fresh vegetables should be checked and sorted for ripeness .should be inspected for decay .dry products should be kept in tightly sealed containers .

A review of the facility's policy Infection Prevention and Control, dated 10/6/2017, revealed, The goals of the infection prevention and control program are to: A. Decrease the risk of infection to residents and personnel . C. Identify and correct problems relating to infection prevention and control practices .D. Maintain compliance with state and federal regulations related to infection and prevention .

On 07/14/24 at 9:07 AM, during an interview and observation of the kitchen with the Cook, there were three (3) green bell peppers that had soft, pliable spots and areas of white biological growth. There were 15 containers of seasonings that were not closed, and the seasonings were exposed. The [NAME] acknowledged the overly ripe bell peppers and the exposed seasonings. The [NAME] reported she was unaware the produce was over-ripe and reported she and the Dietary Manager (DM) were responsible for maintaining food quality in the kitchen.

On 07/15/24 at 11:14 AM, during an observation, the [NAME] picked up a glove from the floor and placed it

on a food prep table where pureed tomatoes and sandwiches were being prepared.

On 07/15/24 at 11:16 AM, in an interview with the Cook, she acknowledged that she had picked up a glove off the floor and placed it on the food prep table. The cook stated she knew food was being prepared on the table, but she did not want to place the glove back into the container with clean gloves. She confirmed the floor was considered dirty and the glove should have been discarded appropriately.

On 07/15/24 at 1:24 PM, an interview with the DM revealed she was aware of the issues regarding spoiled peppers, exposed seasonings, and the [NAME] placing a glove on the food prep table from the floor. The DM stated it was the responsibility of the cook and herself to make sure spoiled foods were discarded. The DM reported whoever opened an item should make sure it was not left open, with the contents exposed. The DM stated she expected spoiled foods to be discarded and the seasonings to be closed. She also stated she expected items that were picked up off of the floor are discarded appropriately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 255244 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255244 B. Wing 07/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunplex Sub-Acute Center 6520 Sunscope Drive Ocean Springs, MS 39564

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 07/17/24 at 9:24 AM, an interview with the Administrator stated the issues in the kitchen should not have occurred. It was her expectation that items be stored and discarded appropriately. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 255244 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255244 B. Wing 07/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunplex Sub-Acute Center 6520 Sunscope Drive Ocean Springs, MS 39564

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 37415

Residents Affected - Many Based 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.

Findings include:

A review of the provider's [NAME] reporting data revealed the facility triggered excessively low weekend staffing and one star staffing rating for the second quarter of the 2024 fiscal year.

A review of the facility's policy titled, Staffing Policy, reviewed 10/2022 revealed, . 4. Direct care staffing information per day (including agency and contract staff) is submitted to the Centers for Medicare and Medicaid Services (CMS) payroll-based journal system on the schedule specified by CMS but no less than once a quarter .

During an interview on 7/17/24 at 9:00 AM, the Senior Director of Operations (SDO) explained she was responsible for sending staffing numbers to CMS. The SDO also said the staffing punches were pulled from Paylocity (online payroll software) and sent to CMS. The SDO also explained she notified the Administrator that the facility triggered for low weekend staffing. The SDO said she asked if there was anyone that was coded wrong which would cause the discrepancy.

During an interview on 7/17/24 at 10:00 AM, the Business Office Manager (BOM) explained the facility failed to accurately code several employees when submitting the PBJ. The BOM said she attended a mini boot camp with the company on May 25, 2024. During this boot camp, it was brought to her attention that several employees who work for their facility do multiple jobs that have several different codes. If those individuals work the floor on weekends, those codes must be put in manually or the system would go back to their primary code. This would make the PBJ look like the staff did not work on those weekend days. The BOM stated when she came back to the facility, she did an audit and noted several days this occurred in the second quarter. The days this occurred were 2/17/24, 2/18/24, 3/9/24, 3/10/24, 3/30/24, and 3/31/24.

A record review of the facility's Weekly Summary of Hours Report revealed Registered Nurse (RN) #1 worked 2/17/24, 3/9/24, and 3/10/24. The RN's primary position is Transitional Care Unit (TCU) Manager, which did not show that she was coded as a floor nurse for those days. Certified Nursing Assistant (CNA) #2 worked as a CNA on 3/2/24. Her primary position is Transportation Aide. CNA #3 worked as a CNA on 3/2/24. The CNA's primary position is Transportation Aide. Licensed Practical Nurse (LPN) #3 worked on 2/17/24, 2/18/24, and 3/10/24. This nurse's primary position is Medical Records. CNA #4 worked on 2/17/24, 2/18/24, 3/10/24, 3/30/24, and 3/31/24. The CNA's primary position is Dietary Aide. The Director of Nursing (DON) worked on 3/31/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 255244 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255244 B. Wing 07/17/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sunplex Sub-Acute Center 6520 Sunscope Drive Ocean Springs, MS 39564

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 During an interview on 7/17/24 at 10:30 AM, the DON explained she was notified on 6/3/24 the facility triggered low staffing in the second quarter because of the inaccurate codes. The DON said she was told Level of Harm - Minimal harm or that the BOM as well as the DON would have to manually code staff that work weekends that do not potential for actual harm normally provide direct care.

Residents Affected - Many During an interview on 7/17/24 at 12:30 PM, the Administrator confirmed the facility triggered for low weekend staffing and is a one-star facility. The Administrator stated she had only been the Administrator for three (3) weeks at this facility. The Administrator said she was informed that the facility had a problem with

the right code being submitted to CMS if the staff works multiple positions. She was told the DON and BOM would manually place the correct codes in the system. The Administrator said she thinks this will fix the problem.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 255244