Deficiency Records for The Massachusetts Veterans Home at Chelsea
Updated as of March 01, 2024
A list of the most recent deficiencies for The Massachusetts Veterans Home at Chelsea. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-08-03 | 2023-09-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-08-03 | 2023-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-03 | 2023-09-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-03 | 2023-09-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-03 | 2023-09-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-08-03 | 2023-09-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-08-03 | 2023-09-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-03 | 2023-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-11 | 2023-08-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-11 | 2023-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-11 | 2023-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-11 | 2023-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-11 | 2023-08-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-11 | 2023-08-17 | N |
| Develop a communication plan. | Fire Safety | 2023-08-11 | 2023-08-17 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-08-11 | 2023-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-08-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-11 | 2023-08-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-22 | 2021-11-04 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-22 | 2021-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-22 | 2021-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-22 | 2021-11-04 | N |
| Provide or obtain dental services for each resident. | Health | 2021-10-22 | 2021-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-28 | 2021-08-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-28 | 2021-05-18 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-09 | 2019-10-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-10-09 | 2019-10-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-21 | 2019-10-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-21 | 2019-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-21 | 2019-10-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-21 | 2019-10-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-21 | 2019-10-04 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-21 | 2019-10-04 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-21 | 2019-10-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-08-21 | 2019-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-21 | 2019-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-21 | 2019-10-04 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-08-21 | 2019-10-04 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-08-21 | 2019-10-04 | N |
