Inspection Report Summary
The most recent inspection on May 27, 2025, identified deficiencies related to food allergy management and staffing levels. Earlier inspections showed a pattern of similar issues, including failures in medication administration, dietary services, and maintaining required staffing hours. Complaint investigations substantiated violations involving resident care, documentation, and staff conduct, with no fines or license actions listed in the available reports. Prior complaints often involved substantiated issues with care planning, clinical record accuracy, and resident rights, including a substantiated sexual harassment case in early 2023. The facility’s inspection history shows ongoing challenges with staffing and care practices, with no clear trend of sustained improvement or worsening.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
93% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 200
Capacity: 216
Deficiencies: 0
May 27, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #44347 and #44355.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in the attached violation letter dated 2025-06-10.
Complaint Details
Complaint Investigation #44347 and #44355 were the basis for this inspection. Violations were substantiated as indicated by the attached violation letter.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hinds | Administrator | Personnel contacted during the inspection. |
| Felicia Richards | DON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Plan of Correction
Census: 200
Deficiencies: 2
May 27, 2025
Visit Reason
An unannounced visit was made to Chelsea Place Care Center LLC on May 27, 2025, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations related to complaints.
Findings
Two violations were identified: 1) Failure to prevent serving food to a resident with documented food allergies, and 2) Failure to maintain staffing levels to meet minimum requirements for direct care hours. Plans of correction were submitted addressing education, audits, and staffing meetings.
Complaint Details
The visit was complaint-related involving Complaint #44347 and #44355. The complaints concerned food allergy management and staffing levels.
Deficiencies (2)
| Description |
|---|
| Failure to prevent serving food items to Resident #2 that he/she was allergic to, including mayonnaise and eggs. |
| Failure to maintain staffing levels to meet minimum requirements of 3.0 hours of direct care per resident, resulting in a shortage of 80 hours on 5/14/25. |
Report Facts
Census: 200
Combined hours worked: 354
Required combined hours: 434
Staffing shortage hours: 80
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter and contact for questions regarding violations |
| Judith Konow | Administrator | Named as responsible for overseeing the plan of correction process |
| Director of Food Service | Interviewed regarding food allergy process and identified failures in allergy documentation and food service | |
| Director of Nursing | DON | Interviewed regarding responsibility for resolving food allergy issues and staffing shortage review |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 216
Deficiencies: 0
Mar 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #43351 and #42743.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in the attached violation letter dated 2025-04-02.
Complaint Details
Complaint Investigation #43351 and #42743 were the basis for this visit. Violations were substantiated as indicated by the attached violation letter.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hinds | Administrator | Personnel contacted during the inspection. |
| Felicia Richards | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Renewal
Census: 200
Capacity: 216
Deficiencies: 0
Mar 17, 2025
Visit Reason
A desk audit was conducted for the survey with EID 3.17.25 as part of the facility's licensing renewal process.
Findings
Tags 697 and 804 and the corresponding violations have been corrected as of 2025-04-25, and no new non-compliance was identified during the desk audit.
Report Facts
Licensed Bed Capacity: 216
Census: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Konow-Hinds | Administrator | Contacted during the inspection and notified by phone about correction of violations |
Inspection Report
Plan of Correction
Census: 203
Deficiencies: 3
Mar 17, 2025
Visit Reason
An unannounced visit was made to Chelsea Place Care Center LLC on March 17, 2025, by the Department of Public Health for the purpose of conducting multiple investigations related to regulatory compliance.
Findings
The report identifies multiple violations including failure to administer prescribed pain medication, inadequate dietary services with unpalatable meals, and failure to maintain required staffing levels. Plans of correction include staff education, audits, and oversight responsibilities assigned to the Director of Nursing and Administrator.
Complaint Details
The visit was complaint-related, involving complaints #42743 and #43351. Specific substantiation status is not stated.
Deficiencies (3)
| Description |
|---|
| Failure to administer prescribed liquid Oxycodone pain medication as ordered, resulting in resident pain. |
| Failure to provide meals that were palatable, attractive, and at an appetizing temperature for residents with severe protein malnutrition. |
| Failure to maintain staffing levels to meet minimum requirements, resulting in a shortage of nursing and nurse aide hours. |
Report Facts
Census: 203
Staffing shortage hours: 56.51
Deficiency audit period: 30
Plan of correction completion date: April 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter and contact for questions regarding violations |
| Judith Konow | Administrator | Facility Administrator addressed in the notice and responsible for oversight |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication administration and facility medication shortage |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and responsible for overseeing plan of correction |
Inspection Report
Complaint Investigation
Census: 211
Capacity: 216
Deficiencies: 0
Mar 5, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by Complaint Investigation #43163.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint Investigation #43163 was the basis for the visit. Violations were not identified at the time of inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hinds | Administrator | Personnel contacted during the inspection. |
| Glenna Fried | LCSW | Report submitted by. |
Inspection Report
Plan of Correction
Census: 194
Capacity: 216
Deficiencies: 0
Jan 16, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a violation letter dated 2025-01-11.
Findings
All federal violations numbered 1 through 18 were identified as corrected as of 2024-12-18. The Administrator was notified on 2025-01-16 that all federal violations were corrected.
Report Facts
Federal Violations corrected: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Konow | Administrator | Notified of correction of all federal violations |
Inspection Report
Renewal
Census: 193
Capacity: 216
Deficiencies: 0
Jan 3, 2025
Visit Reason
The inspection was conducted as a desk audit related to the renewal of the facility's license.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Hines | Administrator | Personnel contacted during the inspection. |
| Barbara Greenhill | RN | Report submitted by. |
Inspection Report
Renewal
Census: 201
Capacity: 216
Deficiencies: 0
Nov 8, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection and included complaint investigations for CT 41709, CT 41708, and CT 41365.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, with attached violation letters referenced.
Complaint Details
Complaint investigations were conducted for CT 41709, CT 41708, and CT 41365; no substantiation status is explicitly stated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow | Administrator | Personnel contacted during the inspection |
| Felicia Richards | DNS | Personnel contacted during the inspection |
| Michelle Pavlonis | Survey Team Leader | Named as Survey Team Leader |
| Connie Greene | Supervisor | Named as Supervisor |
Inspection Report
Census: 199
Capacity: 216
Deficiencies: 0
Sep 18, 2024
Visit Reason
The inspection was conducted as a desk audit on 9/18/2024 to review compliance with licensing requirements.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Pellici | DNS | Personnel contacted during the inspection on 9/18/24 at 1:27 PM |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 19, 2024
Visit Reason
Unannounced visits were made to Chelsea Place Care Center to conduct multiple investigations by the Facility Licensing and Investigations Section of the Department of Public Health.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were noted during the visits, including failure to obtain consent for room searches and failure to ensure resident dignity and respect during searches.
Complaint Details
The visit was related to complaints CT #'s 24927, 25304, 25896, 26623. The report does not state substantiation status.
Deficiencies (1)
| Description |
|---|
| Failure to obtain signed consent for room searches, no documented reason for room searches, and no completion of Resident Room Search Work Sheets per facility policy. |
Report Facts
Complaint numbers: 4
Plan of correction submission deadline: 2024
Audit period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction instructions |
Inspection Report
Plan of Correction
Census: 201
Capacity: 216
Deficiencies: 0
Jun 7, 2024
Visit Reason
A desk audit was conducted to review the implementation of the plan of correction for violations identified in a prior violation letter dated 4/1/24.
Findings
The desk audit found that violations #1, #2, #3, and #4 were corrected as of 5/13/24, and the administrator was notified by telephone that all violations were corrected.
Report Facts
Violations corrected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hines | Administrator | Notified by telephone that all violations were corrected |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 216
Deficiencies: 0
Jun 6, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation for Complaint #39157 and #39310 at Chelsea Place Care Center.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
The visit was complaint-related for Complaint #39157 and #39310. Violations were not identified at the time of inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Perrin | DNS | Personnel contacted during inspection |
| Judith Konow-Hinds | Administrator | Personnel contacted during inspection |
| Glenna Fried | LCSW SWC | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 216
Deficiencies: 0
Apr 30, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #37612 and #38426.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
The visit was complaint-related referencing Complaint Investigation #37612 and #38426. No violations were substantiated during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hinds | Administrator | Personnel contacted during the inspection. |
| Donna Perrin | DNS | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Signature of FLIS Staff and report submitter. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 21, 2024
Visit Reason
Unannounced visits were made to Chelsea Place Care Center by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint CT #37414.
Findings
The investigation identified multiple violations including failure to develop care plans for refusals of care, failure to ensure timely notification of significant weight loss to dietician and physician, incomplete and inaccurate clinical records, and failure to maintain proper documentation of wound care and medication administration.
Complaint Details
Complaint CT #37414 triggered the investigation. The complaint involved issues with care planning, weight loss monitoring, clinical record accuracy, and medication administration documentation. The complaint was substantiated as violations were found.
Deficiencies (4)
| Description |
|---|
| Failure to identify a care plan for refusals of care, medications, or wound care treatment. |
| Failure to ensure timely notification of dietician and physician regarding significant weight loss. |
| Failure to ensure clinical record was complete and accurate including treatment documentation and timely medical record access. |
| Failure to provide Medication Administration Record (MAR) for December 2023. |
Report Facts
Refusals of medications: 10
Refusals of wound care: 4
Weight difference: 12.6
Weight loss percentage: 10.33
Dates of wound care documentation missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of the notice letter regarding the investigation. |
| Judith Konow | Administrator | Administrator of Chelsea Place Care Center addressed in the notice. |
Inspection Report
Census: 199
Capacity: 216
Deficiencies: 2
Nov 16, 2023
Visit Reason
A desk audit was completed on 11/16/23 to review the implementation of the plan of correction for the violation letter dated 8/16/23.
Findings
Violations #1 (F656) and #2 were corrected as of 9/18/23. On 11/16/23, the DNS Donna Perrin was notified via telephone that all violations were corrected.
Deficiencies (2)
| Description |
|---|
| Violation #1 (F656) |
| Violation #2 |
Report Facts
Licensed Bed/Bassinet Capacity: 216
Census: 199
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Perrin | DNS | Notified via telephone that all violations were corrected |
| Barbara Greenhill | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Census: 192
Capacity: 234
Deficiencies: 1
Jan 6, 2023
Visit Reason
An unannounced visit was made to Chelsea Place Care Center on January 6, 2023, for the purpose of conducting a complaint investigation related to allegations of sexual harassment by a facility employee.
Findings
Deficiencies and violations of the General Statutes of Connecticut and regulations were identified during the visit, including substantiated allegations that a housekeeper sexually harassed Resident #1. The housekeeper was terminated on October 5, 2022, following the investigation.
Complaint Details
Complaint Investigation #33595 was conducted. The facility substantiated the allegations against the housekeeper based on interviews with staff, residents, and witnesses. The housekeeper was terminated on 10/5/22. The Administrator took corrective actions including re-education of employees and interviews to ensure understanding of policies.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Resident #1 was free from sexual harassment by a facility employee, including inappropriate comments and gestures by a housekeeper. |
Report Facts
Licensed Bed Capacity: 234
Census: 192
Complaint Number: 33595
Date of onsite inspection: Jan 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow-Hinds | Administrator | Personnel contacted and involved in the investigation |
| Nicholas Tomczyk | Nurse Consultant | Conducted the licensing inspection and complaint investigation |
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding the violation and plan of correction |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 234
Deficiencies: 2
Oct 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #33088 to assess violations of Connecticut State regulations and statutes.
Findings
The facility was found to have violations related to resident rights and safety, including failure to allow residents to smoke as per physician orders and inadequate reporting of a physical altercation incident. The facility also failed to ensure timely notification of reportable incidents to the State Agency.
Complaint Details
Complaint #33088 was investigated. The complaint involved resident rights violations related to smoking policies and failure to report a physical altercation incident timely. The complaint was substantiated with findings of noncompliance.
Deficiencies (2)
| Description |
|---|
| Failure to allow residents to smoke per physician orders and facility policy, leading to resident dissatisfaction and safety concerns. |
| Failure to report a physical altercation incident immediately and timely to the State Agency as required. |
Report Facts
Residents reviewed: 6
Residents reviewed: 7
Incident report delay: 21.97
Census: 194
Total capacity: 234
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow | Administrator | Named in relation to smoking policy and incident reporting findings. |
| Donna Perrin | Director of Nursing Services (DNS) | Named in relation to smoking policy and incident reporting findings. |
| Maureen Golas-Markure | Supervising Nurse Consultant | Author of the notice letter regarding complaint investigation and plan of correction. |
Inspection Report
Follow-Up
Census: 197
Capacity: 234
Deficiencies: 0
Aug 16, 2022
Visit Reason
The visit was conducted to review the implementation of the plan of correction for the violation letter dated 4/21/22.
Findings
An unannounced visit was conducted to review the implementation of the plan of correction. Staffing was reviewed from 8/1/22 through 8/12/22 and met the minimum qualifications of the State of Connecticut Public Health Code. Violations #1 through #10 were corrected as of 5/25/22 and the administrator was notified.
Report Facts
Licensed Bed Capacity: 234
Census: 197
Violations corrected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Perin | DNS | Personnel contacted during inspection |
| Judy Birtwistle | SNC | Survey Team Leader and report submitter |
| Judy Konow | Administrator notified of corrections |
Inspection Report
Renewal
Census: 262
Capacity: 284
Deficiencies: 9
Mar 7, 2022
Visit Reason
Unannounced visits were made to Chelsea Place Care Center to conduct a Re-Certification Survey to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a licensing renewal inspection.
Findings
Violations of the Regulations of Connecticut State Agencies and General Statutes were identified, including deficiencies related to resident dignity and privacy, facility cleanliness and maintenance, medical record accuracy, resident care planning, and dietary services. The facility submitted plans of correction for each violation with specified completion dates.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure a urinary device was covered with a privacy bag for Resident #25. |
| Facility failed to maintain residents' rooms and furnishings in a clean, safe, homelike, and sanitary manner with good repair. |
| Facility failed to ensure the coding of the MDS assessment information was accurate for multiple residents. |
| Facility failed to invite and include Resident #25 in the Resident Care Planning process. |
| Facility failed to develop a comprehensive person-centered plan of care consistent with residents' rights. |
| Facility failed to ensure care and services were provided to maintain good grooming or personal hygiene for Residents #18 and #118. |
| Facility failed to provide rehabilitation screening per policy to Resident #18. |
| Facility failed to ensure dishware and utensils were cleaned and sanitized according to policy and manufacturer's recommendations. |
| Facility failed to maintain the dumpster and compactor area in a clean and sanitary manner. |
Report Facts
Licensed Bed Capacity: 284
Census: 262
Inspection Dates: Inspection conducted on 3/7, 3/8, 3/9, and 3/10 of 2022
Plan of Correction Completion Date: Most plans of correction have a completion date of 5-31-22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed the violation letter and plan of correction documents |
| Judith Konow | Administrator | Named as facility administrator and involved in findings related to Resident #25 |
| Donna Perron | DNS (Director of Nursing Services) | Named as personnel contacted and involved in findings related to Resident #25 |
| LPN #1 | Interviewed regarding urinary catheter bag privacy policy and practice | |
| LPN #4 | Interviewed regarding scheduling and notification for care plan meetings | |
| RN #3 | Interviewed regarding MDS coding errors and clinical record reviews | |
| RN #2 | Interviewed regarding care plan meetings and documentation | |
| Director of Maintenance | Interviewed regarding maintenance issues and facility cleanliness | |
| Director of Housekeeping | Interviewed regarding housekeeping and cleanliness issues | |
| Food Service Director | Interviewed regarding dishwasher sanitizing and dietary services |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 234
Deficiencies: 3
Apr 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #29999 regarding alleged violations of Connecticut State regulations.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the complaint investigation. The facility was found to have deficiencies related to abuse allegations, failure to ensure timely fall reporting and assessment, and incomplete clinical documentation.
Complaint Details
Complaint #29999 triggered the investigation. The complaint involved allegations of mistreatment and failure to provide incontinent care. The investigation found the allegations were not fully investigated and the facility failed to report and investigate the mistreatment allegations timely.
Deficiencies (3)
| Description |
|---|
| Failure to ensure adequate supervision to prevent an accident and timely reporting and assessment of a fall involving Resident #1. |
| Failure to ensure clinical records were complete and accurate, including timely documentation when a resident was observed on the floor. |
| Failure to investigate allegations of mistreatment related to Resident #1. |
Report Facts
Licensed Bed Capacity: 234
Census: 189
Inspection Date: Apr 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow | Administrator | Named in relation to findings and interviews during the complaint investigation. |
| Donna Perrin | Director of Nursing Services (DNS) | Named in relation to findings and interviews during the complaint investigation. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice letter regarding complaint investigation. |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 234
Deficiencies: 1
Apr 29, 2021
Visit Reason
An unannounced visit was made to Chelsea Place Care Center to conduct a complaint investigation based on Complaint Investigation #29999.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified related to neglect allegations involving Resident #1, including failure to investigate allegations of mistreatment and inadequate incontinent care.
Complaint Details
Complaint Investigation #29999 was substantiated with findings of neglect related to Resident #1's care and failure to investigate allegations properly.
Deficiencies (1)
| Description |
|---|
| Failure to ensure allegations of mistreatment were investigated for Resident #1, including issues with incontinent care and staff encouragement to use briefs improperly. |
Report Facts
Licensed Bed Capacity: 234
Census: 189
Complaint Number: 29999
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow | Administrator | Named in relation to findings and investigation of allegations. |
| Donna Perrin | Director of Nursing Services (DNS) | Named in relation to findings and investigation of allegations. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed the notice and correspondence related to the complaint investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2021
Visit Reason
A Complaint Investigation Survey was conducted at Chelsea Place Care Center to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
Deficiencies were cited as a result of the complaint investigation survey conducted at the facility.
Complaint Details
The survey was complaint-related as indicated by the description of the survey as a Complaint Investigation Survey, ACTS Reference Number 29999.
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 29, 2021
Visit Reason
An unannounced visit was made to Chelsea Place Care Center on March 29, 2021 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to complaint #29774.
Findings
The facility was found to have failed to ensure adequate supervision to prevent an accident, timely reporting and assessment after a fall, and complete and accurate clinical documentation when a resident was observed on the floor. The investigation identified issues with staff not reporting allegations of mistreatment and failure to follow fall management protocols.
Complaint Details
Complaint #29774 triggered the investigation. The complaint involved allegations of mistreatment and failure to properly report and investigate a fall incident involving Resident #1. The allegations were substantiated based on interviews and record reviews.
Deficiencies (2)
| Description |
|---|
| Failure to ensure adequate supervision to prevent an accident and timely reporting and assessment after a fall for Resident #1. |
| Failure to ensure clinical records were complete and accurate, including timely documentation when a resident was observed on the floor. |
Report Facts
Complaint number: 29774
Dates related to Resident #1's fall and assessments: Fall incident on 2/1/2021; various assessments and documentation dated between 2/1/2021 and 3/31/2021
Plan of correction submission deadline: Plan of correction to be submitted by April 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Author of the letter regarding the inspection and plan of correction |
| LPN #1 | Named in findings related to failure to report fall and mistreatment allegations | |
| LPN #2 | Named in findings related to failure to report mistreatment allegations | |
| RT #1 (Recreation Therapist) | Named in findings related to fall incident and failure to report | |
| Administrator | Interviewed regarding failure to report mistreatment allegations | |
| DNS (Director of Nursing Services) | Interviewed regarding failure to report mistreatment allegations and fall incident | |
| Physical Therapist #1 | Interviewed regarding Resident #1's mobility and fall prevention | |
| RN #1 | Interviewed regarding assessments and notifications after fall | |
| APRN #1 | Notified after fall incident and involved in ordering diagnostics | |
| ADNS | Educated LPN #1 on fall and incident reporting policy |
Inspection Report
Routine
Census: 196
Capacity: 243
Deficiencies: 0
Oct 7, 2020
Visit Reason
The inspection visit was conducted as a focused infection control COVID survey.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The report was submitted with scanned and attached documentation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Perrin | DNS | Personnel contacted during the inspection. |
| Felicia Richards | ADNS | Personnel contacted during the inspection. |
Inspection Report
Abbreviated Survey
Census: 196
Capacity: 234
Deficiencies: 0
May 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility has implemented CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 234
Census: 196
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 5, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Routine
Deficiencies: 0
Apr 28, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Routine
Census: 190
Capacity: 234
Deficiencies: 0
Apr 22, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Chelsea Place Care Center.
Inspection Report
Complaint Investigation
Census: 217
Capacity: 234
Deficiencies: 2
Nov 6, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #CT 00026320 to assess violations of Connecticut General Statutes and regulations at Chelsea Place Care Center.
Findings
The investigation found violations related to failure to ensure a resident was assessed by a licensed nurse prior to being moved after an unwitnessed fall, and failure to maintain an accurate behavior tracking log for another resident. Staff education and corrective actions were planned to address these deficiencies.
Complaint Details
Complaint #CT 00026320 was substantiated with findings of noncompliance related to nursing assessment after falls and behavior tracking documentation.
Deficiencies (2)
| Description |
|---|
| Failure to ensure Resident #1 was assessed by a licensed nurse prior to being moved after an unwitnessed fall. |
| Failure to ensure the behavior tracking log for Resident #2 was accurate. |
Report Facts
Licensed Bed Capacity: 234
Census: 217
Complaint Number: 26320
Plan of Correction Submission Deadline: Nov 28, 2019
Audit Period: 30
Completion Date: Jun 12, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Konow | Administrator | Named as personnel contacted during inspection and recipient of notices. |
| Karen Gworek | Supervising Nurse Consultant | Signed the violation letter related to Complaint #26320. |
| Heidi Caron | Supervising Nurse Consultant | Signed the violation letter related to Complaint #25255. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 6, 2019
Visit Reason
An unannounced visit was made to Chelsea Place Care Center by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to Complaint #26320.
Findings
The investigation found that the facility failed to ensure a resident who had an unwitnessed fall was assessed by a licensed nurse prior to being moved, resulting in potential harm. Staff education and policy review were identified as corrective measures.
Complaint Details
Complaint #26320 triggered the investigation. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a resident who had an unwitnessed fall was assessed by a licensed nurse prior to being moved, leading to potential injury. |
Report Facts
Complaint number: 26320
Pain rating: 10
Audit period: 30
Audit start date: Nov 26, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and involved in the complaint investigation |
| Judith Konow | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 3, 2019
Visit Reason
An unannounced visit was made to Chelsea Place Care Center on May 3, 2019, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint investigation with additional information received through May 3, 2019.
Findings
The facility failed to ensure the behavior tracking log for one resident was accurate, with discrepancies noted in documentation and behavior recording. The review identified issues with the behavior tracking log and nursing documentation, and the facility's behavior monitoring policy was partially directed to address these concerns.
Complaint Details
Complaint #25255 was investigated. The complaint investigation concluded on May 3, 2019, with findings of noncompliance related to behavior tracking documentation accuracy.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the behavior tracking log was accurate for targeted behaviors of yelling/screaming, medication refusal, intrusive behavior, physical aggression, paranoia, and increased agitation for one resident. |
Report Facts
Complaint number: 25255
Completion date for plan of correction: Jun 12, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Caron | Supervising Nurse Consultant | Signed letter directing plan of correction and overseeing complaint investigation |
| Judith Konow | Administrator | Facility administrator addressed in the letter and responsible for compliance |
Inspection Report
Plan of Correction
Deficiencies: 4
Jan 22, 2019
Visit Reason
Unannounced visits were made to Chelsea Place Care Center commencing on January 22, 2019 and concluding on January 31, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
The report identifies multiple violations related to clinical record reviews, medication administration, resident safety, respiratory care, and resident rights. Specific deficiencies include failure to maintain visual contact with a resident at risk for elopement, failure to conduct respiratory assessments, incomplete clinical records, and medication administration errors.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure PICC line was measured upon admission and weekly for one resident. |
| Facility failed to maintain visual contact with a resident at all times while out on a medical appointment, resulting in the resident leaving unattended. |
| Facility failed to conduct respiratory assessments on a resident to monitor treatment effectiveness for an upper respiratory infection. |
| Facility failed to ensure clinical record was complete and accurate for a resident. |
Report Facts
Dates of visits: January 22, 2019 to January 31, 2019
Medication administration frequency: 24
Medication order duration: 17
Medication administration times: 8
Resident visit supervision times: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
Inspection Report
Complaint Investigation
Census: 220
Capacity: 234
Deficiencies: 3
Jun 20, 2018
Visit Reason
An unannounced visit was made to Chelsea Place Care Center on June 21, 2018, by a representative of the Department of Public Health for the purpose of conducting an investigation related to complaint investigation #23616 and review of violation letters dated 7/05/18.
Findings
Violations of the General Statutes of Connecticut and regulations were identified, including failure to complete skin assessments, failure to provide behavioral care per care plan, and failure to ensure clinical records were complete and accurate. The facility was found to have deficiencies related to resident care, documentation, and abuse allegations.
Complaint Details
Complaint investigation #23616 was substantiated with violations identified. The facility failed to complete required skin assessments, provide behavioral care per plan, and maintain accurate clinical records. Abuse allegations involving Resident #1 were investigated with findings of staff pushing and inappropriate handling. The facility was required to submit a plan of correction.
Deficiencies (3)
| Description |
|---|
| Failure to complete a skin assessment as per facility policy for Resident #1 at risk for pressure ulcers. |
| Failure to ensure behavioral care and services were provided per the care plan for Resident #1. |
| Failure to ensure clinical records were complete and accurate, including documentation of abuse allegations for Resident #1. |
Report Facts
Licensed Bed Capacity: 234
Census: 220
Complaint Investigation Number: 23616
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marlene Aquino | RN, Acting DNS | Personnel contacted during inspection and involved in findings related to skin assessments and care. |
| Laura Jones | Regional Clinical Nurse | Personnel contacted during inspection. |
| Judith Konow | Administrator | Named in relation to findings and correspondence regarding violations and plans of correction. |
| Laura Trombley Norton | Nurse Consultant | Signed report and involved in inspection process. |
| Cher Michaud | RN, Supervising Nurse Consultant | Signed correspondence related to complaint #23174. |
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