Chelsea Retirement Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure opened food items were dated, and had a use by date in a current facility census of 83 residents.Findings Included:During the initial kitchen tour on 8/04/2025 at 9:15 AM with Dietary Director (DD) J in the [NAME] one kitchen it was observed in one of the refrigerators a bag of opened English muffins that did not have a date that the muffins were opened nor a dated that the muffins were to either be used by (UBD-use by date) or discarded. Further observation revealed that in the same refrigerator there were six loaves of opened bread that did not have the date the loaves were opened nor a UBD. During the main Kitchen tour, it was observed in a refrigerator that a carton of opened milk was not dated with the dated the mild was opened nor was the carton dated with a UBD. Further observation of the main kitchen freezer revealed one opened bag of chicken nuggets, one bag of opened chicken tenders, including patties, and wings that were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure one out of one resident (Resident 91) received toileting assistance per the plan of care.Findings Included:Per the facility face sheet Resident 91 (R91) resided at the facility since 7/31/2025. R91 had diagnoses of muscle weakness and need for assistance with personal care. In an interview on 8/04/2025 at 11:17 AM, R91 stated that he had some incontinence of urine at times because he could not make it to the bathroom on time and said when that occurred, he had to use the commode/urinal. In another interview on 8/06/2025 at 2:04 PM, R91 stated that he used a urinal at times rather than the toilet, because he could not get to the toilet on time. R91 said staff would not be able to get to assist him on time, because he would have urgency to urinate. R91 stated that he had to wear a brief and occasionally would have a wet brief or would have to use the urinal. R91 said he would rather use the toilet and added that he has gotten up on his own to go to the bathroom. Review of a care plan that was in place and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that 1 of 2 residents (R34) reviewed received timely follow-up PASSAR II evaluations and coordination of care, resulting in the delay in mental health services appropriate to their needs. Findings include: Resident #34 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R34 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included major depression, generalized anxiety, bipolar disorder, unspecified dementia, frequent falls and epilepsy. Review of the Pre-admission Screening And Resident Review (PASARR) Level I, dated 6/10/24, reflected R34 had marked yes for the person has current diagnosis and received treatment for mental illness and has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. The PASARR reflected R34 had diagnosis of Bipolar and was taking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement care plan interventions for one of 18 residents reviewed for care plans (Resident #52), resulting in the likelihood of aspiration of food or liquid into the lungs and choking during meals. Findings include: Resident #52 (R52) On 8/06/2024 at 12:36 PM, R52 was observed sitting in a chair in her room eating lunch. A male friend was sitting next to her and stated R52 could not talk, but could shake her head yes or no. R52's care plan dated 6/29/2024 instructed not to share or speak with R52 about medical Information with male visitor present; he was just a friend, and ask him to leave first per family. R52's nutrition at risk care plan dated 7/02/2024 revealed a dysphagia 3 diet (moist, chopped/bite-sized pieces) was ordered and she required full one to one supervision with meals. R52's Minimum Data Set (MDS) with assessment reference date of 7/03/2024, revealed she was admitted to the facility on [DATE] and her cognitive skills for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 05/22/23 at 09:26 A.M., An initial tour of the main food production kitchen was conducted with Chef Manager C. The following items were noted: The South Bend conventional oven(s) exterior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend griddle and side plates were observed soiled with accumulated and encrusted food residue. The MagiKitch'n char broiler backsplash and side plates were observed with accumulated and encrusted food residue, adjacent to the two grate plates. Chef Manager C indicated he would have dietary staff thoroughly clean and sanitize the conventional oven(s), griddle, and char broiler as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote resident bathing preferences in two of two residents reviewed for choices (Resident #44 & #67), resulting in choice of bathing schedule not honored and dissatisfaction. Findings include: Resident #44 (R44) On 5/23/23 at 9:11 AM, R44 was observed sitting in her wheelchair in her room. R44's 1/17/23 and 4/19/23 Minimum Data Set (MDS) assessment, revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 15 (13-15 Cognitively Intact). R44's 1/17/23's MDS assessment indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. R44's 4/19/23 MDS indicated she did not reject care during the 7-day look-back period and required extensive assistance with personal hygiene and bathing. During an interview on 5/23/23 at 9:11 AM, R44 stated her shower was scheduled on Wednesday and Sunday, twice weekly, but would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice for facility indicated transfer for one of four residents reviewed for notice of transfer (Resident #18), resulting in the potential for inappropriate resident transfers/discharges. Findings include: Resident #18 (R18) R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). Director of Nursing (DON) B was interviewed on 5/23/23 at 12:44 PM and confirmed R18 was transferred to the hospital 4/22/23 and returned 4/22/23. DON B also confirmed R18 had a hospital stay from 3/12/23 to 3/14/23. DON B stated she was not able to locate a transfer notice for the above dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a notice of the bed hold policy prior to transfer to the hospital for one of four residents reviewed for transfers (Resident #18), resulting in the potential for information not received. Findings include: Resident #18 (R18) Director of Nursing (DON) B was interviewed on 5/23/23 at 12:44 PM and confirmed R18 was transferred to the hospital 4/22/23 and returned 4/22/23. DON B also confirmed R18 had a hospital stay from 3/12/23 to 3/14/23. DON B was not able to provide evidence from R18's medical record of the bed hold policy provided at time of resident transfer. R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). In review of R18's record, there was not documentation of bed hold policy provided at time of transfers. Review of the facility's Bed Hold Notice Upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to complete a level I Preadmission Screening/Annual Resident Review (PASARR) for one (Resident #18) of one residents reviewed for PASARR, resulting in the potential for lack of appropriate mental health treatment and services. Findings include: Resident #18 (R18) R18's Minimum Data Set (MDS) assessment dated [DATE] revealed he admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-12 Moderate Impairment). Social Worker (SW) U was interviewed on 5/23/23 at 12:44 PM, and confirmed the last completed level 1 was completed on 9/27/21. Following the interview SW U sent a completed level 1 screen dated 5/23/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop an individualized care plan in one of 18 reviewed for care plans (Resident #51), resulting in unmet needs and the potential for delayed treatment for infection. Findings include: Resident #51 (R51) On 5/23/23 at 8:00 AM R51 was observed lying flat in bed, her breakfast tray was observed on the over the bed table and covered. R51 stated waiting for help to eat her breakfast. R51's lips were observed dry and flaking. R51's Minimum Data Set (MDS) with assessment reference date of 4/21/23 indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). The same MDS indicated R51 had diagnosis of urinary tract infection (UTI) in last 30 days of assessment date. In review of nurse's notes dated 5/20/23 at 2:08 AM, identified as a late entry for 5/19/23 at approximately 2:00 AM, the nurse attempted to collect a urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow Professional Standards of care and facility policy for nebulizer administration and blood sugar monitoring/documentation for two Residents (R39 and R73) of 18 residents reviewed, resulting in medications not being administered according to professional standards of care and/or facility policy, and lack of appropriate monitoring and management of diabetes including not following physician orders. Findings include: Review of the, Nebulizer Therapy policy, dated 7/2022, provided by the Director of nursing (DON) B on 5/25/23, reflected, It is the policy of the facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Place ordered medication into nebulizer cup .Assist resident into comfortable position .Connect the nebulizer to a power source .Instruct resident on how to use the nebulizer .Turn the machine on .Keep nebulizer vertical during treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#16) of one resident reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #16 (R16) Review of the medical record revealed R16 was admitted to the facility 03/05/2019 with diagnoses that included Huntington's Disease, depression, insomnia, osteoporosis, dysphagia, panic disorder, dementia, stage 3 kidney disease, gastro-esophageal reflux, hypertension, and vitamin D deficiency. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, revealed R16 did not have a Brief Interview of Mental Status (BIMS) completed because he was rarely/never understood. Section G0400-Functional Limitation in Range of Motions, MDS with same ARD, demonstrated that R16 had impaired upper and lower extremities. The MDS with the same ARD section O- demonstrated that R16 was not receiving skilled therapy services or a Restorative Nursing program. During observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer sufficient fluids and prevent weight loss, in one of four residents reviewed for weight loss and hydration (Resident #51), resulting in a severe weight loss in 1 month and unmet hydration needs. Findings include: Resident #51 (R51) On 5/23/23 at 8:00 AM R51 was observed lying flat in bed, her breakfast tray was observed on the over the bed table and covered. R51 stated waiting for help to eat. R51's lips were dry and flaking. R51 was observed approximately 15 minutes later with staff physically assisting with her meal. R51's Minimum Data Set (MDS) with assessment reference date of 4/21/23 indicated she was admitted to the facility on [DATE]; and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). R51's 4/21/23 MDS revealed she required set up assistance for eating. The same MDS indicated R51 had diagnosis of urinary tract infection (UTI) in last 30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.