A list of the most recent deficiencies for Chelsea Retirement Community. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-25 | 2023-06-30 | 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 | 2023-05-25 | 2023-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-25 | 2023-06-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-25 | 2023-06-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-25 | 2023-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-25 | 2023-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-06-20 | N |
| 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. | Health | 2023-05-25 | 2023-06-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-06-20 | N |
| 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. | Health | 2023-05-25 | 2023-06-20 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-05-09 | 2023-06-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-06-29 | 2022-07-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-29 | 2022-07-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-29 | 2022-07-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-29 | 2022-07-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-29 | 2022-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-29 | 2022-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-29 | 2022-07-28 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-28 | 2022-07-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-30 | 2020-03-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-30 | 2020-03-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-30 | 2020-03-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-30 | 2020-03-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-30 | 2020-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-30 | 2020-03-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-30 | 2020-03-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-30 | 2020-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-30 | 2020-03-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-04 | 2020-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-04 | 2020-03-10 | N |
