Telford Terrace

In the surveyor’s words

From the most serious findings on record at Telford Terrace, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Jan 15, 2022

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of eighteen (18) sampled residents (Residents #217 and #218). Observation, on 01/12/2022 at 10:45 AM, revealed Certified Nurse Aide (CNA) #1 walked out of room [ROOM NUMBER], where Resident #218 had been moved, after testing positive for COVID, and walked up the hallway. […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2022

  Based on observation, interview, and review of the facility's policy, it was determined the facility failed to serve food in a safe manner. Observations, on 01/11/2022, of the resident tray line revealed Cook #1 picked up an alcohol wipe from the floor with a gloved hand. Cook #1 proceeded to wash off the thermometer in the hand sink while wearing the contaminated glove. Continued observation revealed Cook #1 then used an alcohol wipe to sanitize the thermometer and continued to use the same wipe on the thermometer after each food on the tray line. In addition, Cook #1 was observed, on 01/11/2022, walking toward the facility from the parking lot wearing his apron and hairnet. […]

• No harm, potential for more than minimal, patternF638Jan 15, 2022

  Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated 10/2019, it was determined the facility failed to complete the Minimum Data Set (MDS) assessments at least quarterly for four (4) of eighteen (18) sampled residents (Residents #3, #12, #16, and #167). The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, under the section 5.2: Timeliness Criteria revealed the completion date for all non-Admission OBRA (Omnibus Budget Reconciliation Act) and Prospective Payment System (PPS) assessments, the Quarterly Minimum Data Set (MDS) Assessments must be completed not less frequently than every three (3) months. 1. […]

• No harm, potential for more than minimal, patternF761Jan 15, 2022

  Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted standards of practice. Observation revealed the medication storage room contained expired and discontinued medications, as well as medications of residents who had expired. The findings include: Review of the facility's policy titled, Storage of Medication, undated, revealed the facility would store all drugs and biologicals in a secure and orderly manner without crowding. Further review revealed the facility would not keep drugs on hand after the expiration date which appeared on the label. […]

• No harm, potential for more than minimal, isolatedF804Feb 24, 2023

  Based on observation, interview, review of facility recipes, and review of facility Policy, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor and appearance for pureed foods. Observation during lunch tray line, on 02/22/2023, during preparation of the lunch puree meal revealed the CDM used hot water to puree the macaroni and cheese and hot water to blend the barbecue chicken. However, review of the facility Puree Mac [Macaroni]-Cheese recipe, revealed directions to blend with milk and some of the juice from the Mac-Cheese. […]