Inspection Report
Renewal
Census: 35
Capacity: 172
Deficiencies: 3
May 28, 2025
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing requirements and to determine if the facility's license status should remain unchanged.
Findings
The facility was found to be non-compliant with several rules including inadequate monitoring and documentation of bedside assistive devices, multiple instances of undocumented medication administration, and missing sanitizer concentration log entries. Violations were established for each of these findings.
Deficiencies (3)
| Description |
|---|
| Failure to follow bedside assistive device policy and ensure resident safety, including lack of documentation and an incomplete service plan for one resident. |
| Multiple instances of undocumented medication administration in May 2025 Medication Administration Records for several residents. |
| Missing entries in Pot-Sink Sanitizer Concentration Logs during April and May 2025 for lunch and dinner shifts. |
Report Facts
Number of staff interviewed and/or observed: 18
Number of residents interviewed and/or observed: 35
Capacity: 172
Medication documentation blank entries: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Eubanks | Administrator | Interviewed regarding bedside assistive devices and resident safety |
Inspection Report
Renewal
Deficiencies: 0
Apr 9, 2024
Visit Reason
The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity over the past year.
Findings
The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Report Facts
License effective date: Apr 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Author of the renewal notification letter |
Inspection Report
Renewal
Census: 45
Capacity: 172
Deficiencies: 4
Apr 26, 2023
Visit Reason
The inspection was conducted as a renewal licensing study for Chelsea Retirement Community to assess compliance with state regulations and determine eligibility for license renewal.
Findings
The facility was found to be non-compliant with several rules including employee tuberculosis screening, designation of shift supervisors, medication administration documentation, and ventilation requirements in the janitor closet. A corrective action plan is required for renewal of the license.
Deficiencies (4)
| Description |
|---|
| Employee tuberculosis screening was not completed within required timeframe. |
| Shift supervisor designation was not properly transcribed onto the staff schedule. |
| Medication administration records for Resident A had multiple dates with missing documentation, making it unclear if medications were administered. |
| Janitor closet vent near memory care units lacked adequate and discernable air flow. |
Report Facts
Number of staff interviewed and/or observed: 15
Number of residents interviewed and/or observed: 45
Facility capacity: 172
Dates with missing medication administration documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Courtnee Knepley | Administrator/Licensee Designee | Interviewed regarding shift supervisor designation |
Inspection Report
Original Licensing
Capacity: 172
Deficiencies: 0
Apr 16, 2015
Visit Reason
The visit was conducted to review and approve a request to increase the licensed capacity of Chelsea Retirement Community from 158 beds to 172 beds by adding 14 'floating' beds in the Glazier Commons area.
Findings
The facility's Glazier Commons area meets the minimum space and accessibility requirements to accommodate the additional 14 beds. Fire safety certification was approved following inspections. It is recommended to increase the total capacity to 172 beds.
Report Facts
Capacity increase: 14
Total capacity: 172
Previous capacity: 158
Units in Glazier Commons: 66
Units in Towsley Village: 86
Beds in Towsley Village: 92
Beds in Glazier Commons: 80
Day/dining/activity space: 3954
Minimum required space: 2400
Barrier free rooms: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Martin | Authorized Representative/Administrator | Submitted request to increase capacity |
| Riyadh Almuktar | Engineer, Bureau of Health Care Services Health Facilities Engineering Section | Conducted room sheet review and confirmed space and room requirements |
| Jeffrey Littleton | Bureau of Fire Services Inspector | Conducted fire safety inspections and approved certification |
| Andrea Krausmann | Licensing Staff | Prepared and signed the addendum report |
| Betsy Montgomery | Area Manager | Approved the addendum report |
Inspection Report
Original Licensing
Capacity: 158
Deficiencies: 0
Nov 3, 2014
Visit Reason
The addendum addresses the use of two laundry processing areas located within the Glazier Commons area of the Chelsea Retirement Community building.
Findings
It was decided that the two laundry areas in Glazier Commons may be used by staff to launder residents' laundry one resident at a time, with no holding of soiled laundry and no processing of linens in these areas.
Report Facts
Capacity: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Martin | Authorized representative/administrator | Involved in discussion and methodology regarding laundry processing areas |
| Andrea Krausmann | Licensing Staff | Author of the addendum report |
| Betsy Montgomery | Area Manager | Approved the addendum report |
| Jay Miedema | Architect | Involved in discussion regarding laundry processing areas |
| Riyadh Almuktar | Engineer, Department of Licensing and Regulatory Affairs Bureau of Health Care Services Health Care Facilities Division | Involved in discussion regarding laundry processing areas |
| James Scott | Manager | Involved in discussion regarding laundry processing areas |
Inspection Report
Original Licensing
Capacity: 158
Deficiencies: 0
Oct 6, 2014
Visit Reason
The addendum to the original licensing study report was conducted to review building modifications including converting semi-private rooms to private rooms, converting resident rooms into activity rooms, and adding a 66-resident room addition to the Towsley Village building, with a request to increase total capacity.
Findings
The facility reduced the number of resident rooms in Towsley Village from 92 to 86 and limited double occupancy rooms to six for a total of 92 beds there. The new Glazier Commons addition has 66 single occupancy rooms, maintaining the total licensed capacity at 158 beds. Laundry facilities in the new addition are designated for resident use only, with staff continuing to use previously approved laundry areas.
Report Facts
Licensed capacity: 158
Resident rooms in Towsley Village: 86
Double occupancy rooms: 6
Resident rooms in Glazier Commons: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Martin | Authorized Representative/Administrator | Requested building modifications and capacity increase |
| Betsy Montgomery | Area Manager | Confirmed laundry facility use and approved report |
| Andrea Krausmann | Licensing Staff | Prepared and signed the addendum report |
Inspection Report
Original Licensing
Capacity: 158
Deficiencies: 0
Apr 16, 2010
Visit Reason
The visit was conducted as an addendum to the original licensing study report to review and approve a requested reduction in the facility's total licensed capacity from 192 beds to 158 beds.
Findings
The facility converted certain areas from licensed home for the aged beds to independent living areas, resulting in a reduction of licensed beds. The Michigan Department of Community Health's Health Facilities Engineering Section inspected and approved the new bed capacities and room configurations, allowing flexibility in designating single or double-bed rooms within the approved capacity.
Report Facts
Licensed bed capacity reduction: 34
Licensed bed capacity: 158
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Author of the addendum report and recommendation |
| Betsy Montgomery | Area Manager | Approved the addendum report and recommendation |
| Sandra Schmunk | Administrator | Facility authorized representative who requested the capacity reduction |
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