Chelsea Gardens

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 6 (Resident # 1 and Resident #2 ) rooms reviewed for environment. The facility failed to ensure Resident # 1 and Resident # 2 rooms were free of odor. The facility failed to ensure the hallway to the conference room and the conference room were free of musty odor This failure could place residents, staff and visitors at risk of infection and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address meet Resident #1's medical, nursing, and mental and psychosocial needs related to his history of choking on food while eating and requirement for mechanical altered diet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received adequate supervision to prevent avoidable accidents for 1 of 8 residents reviewed for accidents (Resident #1) in that: Resident #1 who had a history of choking on food, a diagnosis of dysphagia and required supervision and assistance with eating was given a sandwich and left alone in his bedroom. Approximately 24 minutes after Resident #1 was left alone with a sandwich, he was found by CNA A unresponsive in his room with the sandwich in his hand and food leaking from his mouth. EMS had to clear Resident #1's airway by suctioning emesis (vomit) from his airway and vocal cords, initiated CPR and intubated him. Life saving measures were continued for Resident #1 as he was transported to the hospital and was pronounced deceased . An Immediate Jeopardy (IJ) was identified on 3/6/2026 at 7: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting of alleged violations. [...]

Inspectors wroteBased on interviews and record review the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 5 (CR#1) residents reviewed for weight loss. -The facility failed to ensure CR#1 was monitored for weight loss resulting in a 19.7% or 17.2 lbs. in 3-month period. CR#1 was admitted to hospital with hypernatremia and generalized weakness and a 43-pound weight loss since her last hospitalization. -The facility failed to ensure CR#1 maintained acceptable parameters of nutritional status such as her usual body weight. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure an accurate MDS assessment to reflect the resident's status for 1 of 5 (CR#1) reviewed for MDS assessment accuracy. -The facility failed to ensure CR#1's MDS was updated to accurately reflect her significant change in her weight. This failure placed residents at risk of not receiving care and services to meet the needs of the residents. Findings Included: Record review of CR #'s face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Alzheimer Disease (a progressive disease that destroys memory), cognitive communication deficit (a difficult with communication that is caused by a disruption in cognition), prediabetes, and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. -The door to the medication room was not always closed . -Expired medication (gentamicin IV) in the medication fridge (expiration date 03/29/2024). -Expired gastrostomy feedings (Glucerna 1.5 cal) 7 bottles in the medication room (expiration date June 1st 2024). This deficiency placed the NF at risk for possible drug diversion and residents who received gastrostomy feedings at risk for gastrointestinal complications and decrease quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were dated as opened/preparation discarded after 96 hours. 3. The facility failed to keep food off the floor. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 07/30/24 at 8:15 AM revealed the following. 1. 2 Quarts of High Protein Supplement Drink in the walk-in cooler with a manufacturer expiration date of 5/21/24. 2. A Plastic container of Chocolate Pudding in the walk-in cooler with a used by date 7/27/24. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: - The facility failed to label and date food stored in the dry goods storage, refrigerator, and deep freezer. - There were chemicals stored (by the 3-compartment sink) in an open area in the kitchen. - The kitchen staff did not change gloves when changing tasks. - The staff did not wash their hands upon entering the kitchen and they did not wash hands properly. - The kitchen staff did not use the red sanitizing bucket to wipe down preparation countertops during food prep and meal service. - The kitchen staff failed to wear hairnets properly while working or entering the facility's kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 residents (Resident #7, Resident #16, and Resident #14) of 15 residents reviewed for accidents and supervision had an environment that was as free of accident hazards as possible. -Residents #7 and #16 were at risk for falls. The facility failed to consistently place fall mats next to their beds when the residents were occupying the bed. -Resident #14 was at risk for falls. The facility created an injury hazard by placing the resident's bed table in the pathway of a potential fall. These deficient practices could place residents at risk for injury. Findings Include: Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Dementia. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment and the post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services for 1 of 2 residents (CR # 1) reviewed for an effective discharge process. The facility failed to complete a discharge summary prior to CR#1's discharged . This failure could place residents at risk for incorrect, incomplete, or misleading information recorded regarding discharged or deceased residents and failure in the continuity of care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #20) of 1 resident reviewed for enteral nutrition. -Resident #20 was receiving enteral nutrition via a G-tube. The closed-system formula bag was not labelled with the start time. The deficient practice placed residents who require enteral nutrition at risk for complications including infection if the formula bag was not replaced within a safe timeframe. Findings Include: Record review of Resident #20's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was dysphagia, oropharyngeal phase (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #30) of 1 resident reviewed for respiratory care. -Resident #30's oxygen nasal cannula tubing was dated 2/12 and not stored properly when not in use. -Resident #30's nebulizer mask and tubing were not dated and not stored properly when not in use. This these deficient practices could place residents receiving respiratory care at risk for respiratory infection leading to pneumonia. Findings Include: Record review of Resident 30#'s face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and Asthma. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 1 facility reviewed for posted staffing. -The facility failed to post the daily staffing information for 05/21/2023. This failure could affect all residents and place them at risk of not having access to information regarding staffing data and facility census.