Sunplex Sub-acute Center
Inspection Findings
F-Tag F689
F-F689 (Accident Hazards) when two Certified Nurse Aides (CNAs) improperly positioned a resident in bed, resulting in a fall with an injury.
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. CNA#1 attempted to reach to hold onto the resident, but due to her being slippery, she rolled out of bed.
During an interview with the Director of Nurses (DON) on 1/27/25 at 11:00 AM, she confirmed she reviewed
the CMS-2567 from the survey on 10/3/24. She stated the facility continued to conduct audits to monitor compliance of residents having a safe environment and to prevent accidents as per the plan of correction.
During an interview with the Administrator on 1/27/25 at 11:20 AM, the facility performed audits to monitor
the residents for safety and accident prevention. She commented that she was going to take the concerns regarding accident/hazards back to the (QAPI) committee to again develop action plans and audits.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 255244