I O O F Home and Community Therapy Center

In the surveyor’s words

From the most serious findings on record at I O O F Home and Community Therapy Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Aug 11, 2023

  Based on observation, staff interview, resident interview, resident council minutes, food temperature logs and facility policy review the facility failed to store, prepare, distribute and serve food in accordance with the professional standards for food service safety. This failure resulted in an Immediate Jeopardy to the health, safety and security of the residents. The facility identified a census of 67 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 10, 2023 on August 10, 2023 at 5:19 PM. The Facility Staff removed the immediacy on August 10, 2023 through the following actions: a. Assurance the facility contracted dietary personnel had been educated on proper food storage, preparation and procurement. b. […]

• Immediate jeopardy, patternF684May 5, 2022

  Based on observation, resident, staff and physician interviews and record review, the facility failed to provide timely assessments and interventions for 5 out of 5 residents reviewed (Residents #7, #8, #11, #12 and #13). The facility did not assess and/or did not provide interventions when they did not respond appropriately to low blood pressures (BP), low oxygen saturations (O2 sats), decline in a resident's condition, a resident who went days without a bowel movement, and skilled care assessments on a resident which were not being completed and the resident passed away. […]

• Immediate jeopardy, isolatedF686Mar 17, 2022

  Based on staff interviews, record review, facility policy and procedure, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing, failed to provide the necessary treatment and services to promote the healing of pressure ulcers for which a resident was transferred to the hospital with an infection for one of two residents reviewed (Resident #2). This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 74. Findings include: 1. The Quarterly Minimum Data Set (MDS) completed for Resident #2 with an Assessment Reference Date (ARD) of 2/11/22, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Aug 11, 2023

  Based on observation, clinical record review, staff interview, resident interview, Nurse Practitioner (NP) interview and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 3 residents reviewed, (Resident #1). The facility identified a census of 67 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 2/17/23 indicated Resident #1 had diagnosis that included alzheimer's disease, anxiety and depression. The assessment indicated the resident rarely made self understood or understood others, had severely impaired cognitive skills, continuous inattention and fluctuating disorganized thinking. The resident exhibited physical, verbal and other behaviors 1 to 3 days out of the look back period of 7 days. […]

• No harm, potential for more than minimal, patternF804Mar 21, 2024

  Based on observation, policy review, and staff interview the facility failed to maintain safe holding temperatures of 135 degrees Fahrenheit for hot foods and under 41 degrees Fahrenheit for cold foods to prevent foodborne illness. The facility reported a census of 63. Findings include: Premeal temperatures taken on 3/19/24 at 11:42 AM revealed the pureed vegetables and gravy were not heated to an internal temperature of 135 degrees Fahrenheit ( F) before being served to residents. The vegetables reached a temperature of 125.7 F and the gravy 134.7 F directly before being plated. Post meal temperatures taken at 12:32 PM revealed the following foods did not maintain the internal holding temperature of 135 F: a. Pureed vegetables (on unit): 125.1 F b. Ground Pork (on unit): 100.0 F c. […]