Inspection Reports for
Chelsea Place Care Center LLC

The complaint involved substantiated allegations of sexual abuse by a male housekeeper against Resident #1 and Resident #2. Resident #1 reported inappropriate touching and sexual assault on 11/18/25. Resident #2 reported an attempted kiss and inappropriate behavior approximately one week earlier. The facility was unable to substantiate the allegations due to lack of direct witnesses but took action by terminating the housekeeper.

The facility failed to ensure two residents were protected from sexual abuse by a staff member. Investigations included clinical record reviews, interviews, and documentation, revealing inappropriate touching and attempted sexual contact by the housekeeper. The housekeeper denied the allegations and was terminated during the probationary period.

The complaint investigation was substantiated with multiple incidents of resident-to-resident physical abuse documented, including Resident #2 striking Resident #1 on 3/31/25, Resident #2 slapping Resident #3 on 5/6/25, Resident #2 hitting Resident #4 on 5/19/25, and Resident #6 punching Resident #7 on 5/11/25. Interventions and monitoring were implemented following each incident.

The facility failed to ensure residents were kept safe from abuse, as evidenced by several documented incidents of residents striking or hitting each other, despite interventions and monitoring. The Director of Nursing and staff acknowledged the aggressive behaviors and implemented care plan interventions, but were uncertain if further prevention was possible.

The visit was complaint-related involving Complaint #44347 and #44355. The complaints concerned food allergy management and staffing levels.

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.

The facility failed to provide meals free of allergens to Resident #2, who had documented allergies to mayonnaise and eggs. Despite updated allergy records and staff awareness, Resident #2 was served food containing allergens multiple times, indicating a failure in communication and food service processes.

The visit was complaint-related, involving complaints #42743 and #43351. Specific substantiation status is not stated.

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.

The facility failed to provide safe and appropriate pain management for a resident requiring controlled medication, resulting in a medication shortage and inadequate pain relief. Additionally, the facility failed to provide meals that were palatable, attractive, and served at appropriate temperatures, leading to multiple resident complaints about food quality and service.

The investigation was complaint-driven due to allegations of narcotic diversion by LPN #1. The facility's investigation found discrepancies in controlled substance records and suspected diversion. LPN #1 admitted to diverting Oxycodone for personal use during a Department of Consumer Protection interview. The facility failed to notify the State Agency timely of the misappropriation allegation.

The facility failed to ensure residents were free from misappropriation of medications, specifically Oxycodone, due to missing or incomplete controlled substance distribution records (CDSR), lack of proper documentation of medication administration, and failure to account for missing narcotics. The facility also failed to timely notify the State Agency of the misappropriation allegations. Additionally, documentation deficiencies were found related to resident behaviors and medication administration for one resident.

The facility failed to ensure timely notification to a resident's responsible party regarding Medicare non-coverage, maintain safe and sanitary bathroom environments, and properly manage resident personal clothing labeling and missing items. Observations included unsafe bathroom conditions, environmental damage in resident rooms, and missing resident clothing items.

The facility was found deficient in multiple areas including delayed response to call bells, unsafe and unsanitary environmental conditions, incomplete and untimely care plans, improper respiratory care and tracheal suctioning practices, inadequate infection control measures, food safety violations, and failure to maintain a safe and comfortable environment. Several residents were affected by these deficiencies, though harm was generally minimal or potential.

The complaint investigation involved two issues: inappropriate language used by Social Worker #1 in the presence of residents, and an allegation by Resident #4 that a nursing assistant (NA #1) physically abused them by twisting wrists and pulling hair. The facility unsubstantiated the abuse allegation, concluding NA #1 acted to protect herself and there was no malicious intent.

The facility was found to have failed in ensuring appropriate language was used near residents and failed to protect a resident from physical abuse by a staff member. The abuse allegation was unsubstantiated by the facility, but the resident was subsequently assigned two-person assist for care.

The visit was related to complaints CT #'s 24927, 25304, 25896, 26623. The report does not state substantiation status.

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.

The complaint investigation focused on alleged violations of residents' rights related to leave of absence procedures, unauthorized room searches, failure to provide discharge notices, and denial of readmission after hospitalization. The investigation substantiated these issues for Residents #1 and #2.

The facility failed to ensure residents' rights were respected in multiple areas: improperly restricting leave of absence and visitor rights for Resident #2, conducting unauthorized room searches without consent, failing to issue a 30-day discharge notice for Resident #1, and denying Resident #1 readmission after hospitalization contrary to bed-hold policy. These deficiencies were supported by clinical record reviews, facility policies, interviews, and documentation.

The facility failed to honor resident rights by excluding specific information in the leave of absence policy, including unclear requirements for Travel Passes and physician orders. Additionally, the facility failed to maintain a safe, clean, and homelike environment, with issues such as broken window blinds, scuff marks, dust accumulation, improper storage of wheelchairs, and lack of oxygen signage.

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.

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.

The facility failed to develop a comprehensive care plan addressing refusals of care for a resident with pressure wounds, failed to timely obtain re-weights and notify the dietician and physician of significant weight loss, and failed to ensure accurate and complete clinical documentation including wound care treatments and medication administration records.

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.

The complaint investigation was substantiated with findings that Resident #1 sustained a fracture likely caused by thrashing extremities in bed, and the care plan did not include interventions to reduce safety risks related to this behavior.

The facility failed to develop a comprehensive care plan addressing Resident #1's known behavior of thrashing limbs in bed, which likely contributed to a fracture. Staff interviews and medical assessments confirmed the injury and the lack of appropriate care plan interventions.

The complaint investigation focused on allegations of abuse involving Resident #1 and documentation failures. The findings were substantiated as the facility failed to maintain complete and accurate clinical records, including medication administration and behavior monitoring documentation.

The facility failed to document medication administration timely for multiple medications in May and June 2023, and behavior monitoring documentation for Resident #1 was incomplete for multiple dates in March and July 2023. Interviews with nursing staff confirmed medications were administered but not always documented. The Administrator acknowledged the documentation deficiencies and lack of a policy to ensure completion.

The complaint involved Resident #1 alleging that a nursing assistant used foul language towards him/her and in reference to his/her mother during the 3-11 PM shift on 6/15/23. The facility failed to report the allegation to the Administrator or Director of Nursing immediately. Interviews confirmed the incident and inappropriate language use. The nurse aide involved was suspended from 6/20/23 through 6/28/23.

The facility failed to ensure staff treated the resident with respect and dignity, as a nurse aide used inappropriate and profane language towards Resident #1. Additionally, the facility failed to timely report the allegation of verbal abuse to the Administrator or Director of Nursing at the time it was identified.

The grievance was substantiated as the facility failed to investigate Resident #1's concerns about being left soiled on 4/29/23 and 5/6/23. Education was provided to staff, but no investigation documentation was produced. Resident #1 was discharged before follow-up communication could occur.

The facility failed to conduct a complete investigation into the grievance regarding neglect. Staff education on incontinent care was provided, but documentation of an investigation was not produced, and follow-up communication with the resident was not completed due to discharge.

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 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 #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.

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.

The facility was found deficient in multiple areas including maintenance and cleanliness of resident rooms and furnishings, inaccurate coding of MDS assessments, failure to apply Level II PASRR screening, failure to include residents in care planning meetings, inadequate personal care and grooming assistance, failure to provide appropriate care for range of motion impairments, improper sanitization of dishware and utensils, and unsanitary conditions in the dumpster and compactor area.

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.

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.

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 Investigation #29999 was substantiated with findings of neglect related to Resident #1's care and failure to investigate allegations properly.

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 #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.

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 #CT 00026320 was substantiated with findings of noncompliance related to nursing assessment after falls and behavior tracking documentation.

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 #26320 triggered the investigation. The report does not explicitly state substantiation status.

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 #25255 was investigated. The complaint investigation concluded on May 3, 2019, with findings of noncompliance related to behavior tracking documentation accuracy.

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.

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.

The facility was found deficient in timely physician notification of injury and condition changes, failure to report injuries of unknown origin promptly, inadequate investigation of alleged abuse, failure to follow physician orders for weight monitoring and neurology consults, failure to maintain cleanliness of wheelchairs, failure to ensure use of customized wheelchairs, failure to monitor urinary catheter care, failure to monitor orthostatic blood pressures, failure to document behavioral symptoms, failure to follow up on dental appointments, and failure to maintain wheelchair equipment.

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.

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.