6 Reports
Inspection Report — May 28, 2025
Renewal
Date: May 28, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 3 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (3)
R 325.1921 Governing bodies, administrators, and supervisors: the facility did not follow its bedside assistive device policy and did not adequately ensure resident safety and protection in relation to the use of these devices.
R 325.1932 Resident medications: multiple instances of blank medication administration entries prevented verification that medications were administered as prescribed. Repeat violation.
R 325.1976 Kitchen and dietary: several entries were missing in the Pot-Sink Sanitizer Concentration Logs for lunch and dinner shifts, resulting in a violation.
Report Facts
Corrective action plan due: 15
Inspection Report — Apr 9, 2024
Renewal
Date: Apr 9, 2024
Visit Reason
License renewal notice; no inspection report attached. Administrative review without an on-site visit.
Findings
The license was renewed following an administrative review that revealed substantial compliance with applicable rules.
Inspection Report — Apr 16, 2015
Date: Apr 16, 2015
Visit Reason
Increase capacity from 158 to 172 beds in the Chelsea Retirement Community.
Findings
The capacity of Chelsea Retirement Community was recommended to be increased by 14 beds in the Glazier Commons area, resulting in a total capacity of 172 beds.
Report Facts
Inspection Report — Nov 3, 2014
Date: Nov 3, 2014
Visit Reason
Addendum purpose: To address the use of the two laundry processing areas located within the Glazier Commons area of the building.
Findings
The addendum clarifies that the two laundry areas in Glazier Commons may be used by staff to launder one resident's laundry at a time with no holding of soiled laundry and no processing of linens.
Inspection Report — Oct 6, 2014
Date: Oct 6, 2014
Visit Reason
Addendum to the Original Licensing Study Report for building modifications and capacity changes.
Findings
The total capacity for Chelsea Retirement Community remains at 158 beds with modifications to room configurations and a new addition. Laundry facilities in the new addition will be used solely by residents until washers and dryers are relocated.
Report Facts
Inspection Report — Apr 16, 2010
Date: Apr 16, 2010
Visit Reason
Addendum purpose: reduction in total licensed capacity from 192 beds to 158 beds.
Findings
The facility's total capacity was reduced from 192 to 158 beds in accordance with the specifications of the HFES report for double-bed rooms.
Report Facts
5 CMS Surveys
Inspection Report — Aug 6, 2025
Plan of Correction
Date: Aug 6, 2025
Visit Reason
Plan of correction accepted for deficiencies cited during the survey completed on 08/06/2025.
Findings
Deficiencies were cited related to toileting assistance for Resident 91 and food date marking practices.
Inspection Report — Aug 8, 2024
Plan of Correction
Date: Aug 8, 2024
Visit Reason
Plan of correction letter addressing deficiencies cited in the survey completed on 08/08/2024.
Findings
Two deficiencies were cited related to failure to coordinate mental health services for one resident and failure to implement care plan interventions for another resident, resulting in potential harm.
Deficiencies (2)
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to ensure timely follow-up PASARR Level 2 evaluations and coordination of care for Resident #34, delaying mental health services.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to implement care plan interventions for Resident #52, resulting in the likelihood of aspiration and choking during meals due to lack of one-to-one supervision and incomplete care plan instructions.
Inspection Report — May 25, 2023
Complaint Investigation
Date: May 25, 2023
Visit Reason
Investigation of a complaint received on or before 2023-05-25 about failure to notify resident or representative of bed hold policy upon hospital transfer.
Complaint Details
Failure to notify resident or representative of bed hold policy upon hospital transfer: established.
Findings
The facility failed to provide written notice of the bed hold policy prior to transfer to the hospital for one of four residents reviewed, resulting in potential lack of information.
Deficiencies (1)
F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide this notice for Resident #18 prior to hospital transfer.
Inspection Report — May 25, 2023
Complaint Investigation
Date: May 25, 2023
Visit Reason
Investigation of a complaint received on 2023-05-25 about multiple resident care and facility maintenance issues.
Complaint Details
Resident bathing preferences not honored: established. Failure to provide transfer and bed hold notices for Resident #18: established. Failure to complete PASARR screening for Resident #18: established. Failure to develop individualized care plan for Resident #51: established. Failure to follow nebulizer and blood sugar monitoring protocols for Residents #39 and #73: established. Failure to provide ROM care for Resident #16: established. Failure to maintain adequate nutrition and hydration for Resident #51: established. Failure to clean and maintain food service equipment: established.
Findings
Multiple deficiencies were found including failure to promote resident bathing preferences, failure to provide timely transfer notices, failure to complete PASARR screening, failure to develop individualized care plans, failure to follow professional standards for medication administration and monitoring, failure to provide appropriate range of motion care, failure to maintain adequate nutrition and hydration, and failure to properly clean and maintain food service equipment.
Deficiencies (9)
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: the facility failed to promote resident bathing preferences for Residents #44 and #67, resulting in dissatisfaction and unmet preferences.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide a written notice for facility indicated transfer for Resident #18.
F 0625 Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide notice of the bed hold policy for Resident #18.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to complete a level I Preadmission Screening/Annual Resident Review (PASARR) for Resident #18.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop an individualized care plan for Resident #51 related to urinary tract infection signs and symptoms.
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to follow professional standards for nebulizer administration and blood sugar monitoring/documentation for Residents #39 and #73.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to ensure appropriate treatment and services for contracture management for Resident #16.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to offer sufficient fluids and prevent weight loss for Resident #51, resulting in severe weight loss and unmet hydration needs.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to effectively clean and maintain food service equipment, including soiled ovens, griddles, char broilers, and missing ventilation filters, increasing the likelihood for cross-contamination and bacterial harborage.
Inspection Report — May 9, 2023
Complaint Investigation
Date: May 9, 2023
Visit Reason
Investigation of a complaint received on 2022-07-13 about failure to provide copies of medical records upon written request.
Complaint Details
Failure to provide copies of medical records upon written request: established.
Findings
The facility failed to ensure one resident was provided copies of medical records upon written request and within two working days, resulting in resident rights being infringed upon.
Deficiencies (1)
F 0573 Let each resident or the resident's legal representative access or purchase copies of all the resident's records: the facility failed to provide Resident #1 copies of medical records upon written request within two working days.
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