Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
48% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 83
Deficiencies: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards for residents, including toileting assistance and food safety practices.
Findings
The facility failed to ensure one resident received toileting assistance per the care plan, and failed to properly date mark opened food items in the kitchen according to food safety standards.
Deficiencies (2)
F 0690: The facility failed to provide toileting assistance per the plan of care for one resident, resulting in incontinence and unmet toileting needs.
F 0812: The facility failed to ensure opened food items were dated with an opened date and use-by date in accordance with professional food safety standards.
Report Facts
Current facility census: 83
Toileting assistance frequency: 9
Date survey completed: Aug 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Discussed Resident 91's toileting plan and facility toileting protocols |
| CNA K | Certified Nurse Aid | Provided information on Resident 91's toileting schedule and incontinence status |
| RN G | Registered Nurse | Commented on Resident 91's toileting plan and schedule |
| DD J | Dietary Director | Observed and explained food date marking deficiencies in the kitchen |
Inspection Report
Renewal
Census: 35
Capacity: 172
Deficiencies: 3
Date: 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)
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
Routine
Deficiencies: 2
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including coordination of mental health services and implementation of care plans for residents with specific health needs.
Findings
The facility failed to coordinate timely follow-up mental health evaluations and services for one resident with major mental illness, and failed to implement care plan interventions for another resident, resulting in risks related to aspiration and choking during meals.
Deficiencies (2)
F 0644: The facility failed to coordinate with the appropriate state-designated authority to ensure timely follow-up PASARR Level 2 evaluations and mental health service referrals for one resident with major mental illness.
F 0656: The facility failed to implement care plan interventions for one resident with dysphagia, resulting in the likelihood of aspiration and choking during meals due to lack of required one-to-one supervision and omission of recommended swallowing strategies.
Report Facts
Residents reviewed for care plans: 18
Residents affected: 1
Residents affected: 1
Weight loss: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker F | Reported on PASARR Level 2 evaluation and mental health service coordination for Resident #34 | |
| Certified Nurse Assistant (CNA) O | Interviewed regarding supervision of Resident #52 during meals | |
| Rehabilitation Director P | Verified recommendations for one-to-one supervision with meals for Resident #52 |
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Plan of Correction
Deficiencies: 1
Date: May 25, 2023
Visit Reason
The document is a plan of correction related to a deficiency found during a survey regarding the facility's failure to provide written notice of the bed hold policy to a resident transferred to the hospital.
Findings
The facility failed to provide written notice of the bed hold policy to Resident #18 at the time of hospital transfers on 3/12/23 to 3/14/23 and 4/22/23, resulting in potential lack of information for the resident or representative.
Deficiencies (1)
F 0625: The facility failed to notify the resident or resident's representative in writing about the duration of the bed hold policy during hospital transfers for Resident #18. Documentation of the bed hold policy provided at transfer was not found in the resident's medical record.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident #18's hospital transfers and bed hold policy documentation |
Inspection Report
Routine
Deficiencies: 9
Date: May 25, 2023
Visit Reason
Routine inspection of Chelsea Retirement Community to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, lack of timely transfer and bed hold notices, incomplete PASARR screening, inadequate individualized care plans, improper nebulizer and blood sugar monitoring, insufficient contracture management, inadequate nutrition and hydration, and poor food service equipment maintenance.
Deficiencies (9)
F 0561: The facility failed to promote resident bathing preferences for two residents, resulting in dissatisfaction and unmet bathing schedule preferences.
F 0623: The facility failed to provide timely written notice of transfer for one resident, risking inappropriate transfers/discharges.
F 0625: The facility failed to provide written notice of bed hold policy prior to hospital transfer for one resident, risking lack of information.
F 0644: The facility failed to complete a level I PASARR screening for one resident, risking lack of appropriate mental health treatment.
F 0656: The facility failed to develop an individualized care plan addressing urinary tract infection symptoms for one resident, risking delayed treatment.
F 0684: The facility failed to follow professional standards for nebulizer administration and blood sugar monitoring for two residents, resulting in improper medication administration and monitoring.
F 0688: The facility failed to provide appropriate contracture management and range of motion therapy for one resident, risking worsening contractures and pain.
F 0692: The facility failed to offer sufficient fluids and prevent severe weight loss in one resident, resulting in unmet hydration and nutritional needs.
F 0812: The facility failed to effectively clean and maintain food service equipment, increasing the likelihood of cross-contamination and bacterial harborage affecting 73 residents.
Report Facts
Weight loss percentage: 8.67
Blood glucose missing documentation days: 11
Residents affected by food service equipment deficiencies: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding transfer notices, bed hold policy, PASARR screening, nebulizer and blood sugar monitoring, and contracture management. |
| Assistant Director of Nursing T | Assistant Director of Nursing | Interviewed regarding resident bathing schedule and preferences. |
| Social Worker U | Social Worker | Interviewed regarding PASARR screening completion. |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Observed administering nebulizer treatment improperly. |
| Certified Nurse Assistant G | Certified Nursing Assistant | Interviewed regarding range of motion care provided to resident #16. |
| Team Lead of Therapy F | Team Lead of Therapy | Interviewed and observed regarding contracture management and ROM program for resident #16. |
| Certified Nurse Assistant V | Certified Nursing Assistant | Interviewed regarding resident #51's meal intake. |
| Registered Dietician D | Registered Dietician | Interviewed regarding resident #51's nutritional status and hydration needs. |
| Chef Manager C | Chef Manager | Interviewed regarding food service equipment cleaning and maintenance deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to provide a resident with copies of medical records upon written request within two working days.
Complaint Details
This citation pertains to Intake MI00129641. The complaint was filed by Resident #1's spouse regarding failure to provide medical records. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to ensure that Resident #1 was provided copies of medical records upon written request and within the required timeframe, resulting in an infringement of resident rights. Medical Records staff reported no recollection of the requests and lacked a policy for confirming receipt of records by the requester.
Deficiencies (1)
F 0573: The facility failed to provide Resident #1 copies of medical records upon written request within two working days, infringing on resident rights.
Report Facts
Charge for medical records: 102.31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records staff F | Interviewed regarding medical records requests and facility policy | |
| Director of Nursing B | Director of Nursing | Assisted Resident #1 and spouse in completing medical records request |
Inspection Report
Renewal
Census: 45
Capacity: 172
Deficiencies: 4
Date: 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)
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
Date: 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
Date: 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
Date: 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
Date: 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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