Chelsea Place Care Center LLC

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for Resident Rights, the facility failed to allow Resident #2 to go on a leave of absence (LOA) with a family member and failed to trial unsupervised visitation.

Inspectors wroteBased on clinical record review, facility documentation/policy, and staff/security interviews for two of two residents reviewed for opioid overdose risk (Residents #2 and #6), the facility failed to identify and control accident hazards and provide adequate supervision and safety interventions for residents with known opioid use disorder-by admitting Resident #6 with recent fentanyl use without establishing a completed, risk based plan of care with specific controls (e.g., supervised visits, random room searches, visitor log management, random urine toxicology, and documented substance use disorder (SUD) support/refusal handling), by lacking an overdose/Narcan protocol, by failing to contact law enforcement when illegal drugs were suspected or observed, and by failing to maintain chain of custody for contraband-resulting in Resident #6 requiring two Narcan doses for suspected fentanyl [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for four (4) of nineteen (19) residents (Residents #7, #8, #9 and #10) reviewed for physician's visits, the facility failed to ensure physician orders were signed and dated with each physician visit per the minimum requirements of the Connecticut General Statute 19-13-D8t.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of five (5) residents (Resident #3) reviewed for opioid medication administration, the facility failed to ensure the resident was treated with dignity by changing the form of a prescribed opioid medication to crushed tablets without individualized assessment or honoring the resident's expressed preference.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for a change in condition, the facility failed to notify the physician and licensed nursing staff of a significant change in the resident's condition and failed to notify the physician when ordered interventions were ineffective. Specifically, the resident experienced ongoing vomiting, dry heaving, abdominal pain, and non-verbal signs of distress despite administration of PRN medications, and these changes were not timely reported or escalated.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #6) reviewed for opioid use disorder, the facility failed to develop and implement a person-centered care plan with appropriate interventions to address the resident's identified risk for substance use disorder (SUD) and receipt of Medication Assisted Treatment (MAT).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents (Resident #2 and Resident #5) reviewed for medication administration, the facility failed to maintain complete and accurate medical records by failing to document the administration of as-needed (PRN) medications and the resident's response to those medications in the medication administration record, in accordance with physician orders and facility policy.

Inspectors wroteBased on clinical record review, facility documentation, facility policies and interviews for two of three sampled residents (Resident #1 and Resident #2) reviewed for an allegation of staff-to-resident sexual abuse, the facility failed to ensure Resident #1 and Resident #2 were protected from sexual abuse by a staff member.

Inspectors wroteBased on review of clinical records, interviews, facility documents and facility policy for five (5) of six (6) residents (Resident #1, #2, #3, #4, and #6,) reviewed for abuse, the facility failed to ensure residents were kept safe from abuse.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, and interviews for one (1) of four (4) sampled residents (Resident #2) who had documented food allergies, the facility failed to provide meals that were free of the items Resident #2 was allergic to.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had chronic pain and required a controlled medication for relief, the facility failed to reorder the resident's pain medication to ensure the medication was available to be administered or administer an alternative medication in the absence.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a diagnosis of severe protein malnutrition, the facility failed to provide meals that were palatable, attractive, and at an appetizing temperature for all residents.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for five (5) of eleven (11) residents (Residents #1, 2, 3, 8 and 9) reviewed for abuse, the facility failed to ensure the residents were free from misappropriation of the resident's medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for nine of eleven residents (Residents #1, 2, 3, 4, 5, 6, 7, 8 and 9) reviewed for misappropriation, the facility failed to maintain controlled drug accountability records controls sheets (CDSR) as required.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for five of eleven (11) residents (Residents #1, 2, 3, 8, and 9) reviewed for misappropriation, the facility failed to ensure the State Agency was notified timely of an allegation of misappropriation when an alleged diversion was identified.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #12) reviewed for accidents, the facility failed to ensure complete documentation regarding resident behaviors and failed to ensure that administered medications were signed off and the effectiveness of the medications were documented on in the clinical record. Resident #12's diagnoses included dementia, schizophrenia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12) indicative of a moderate cognitive impairment and required set-up assistance for bed mobility, transfers and ambulation. [...]

Inspectors wroteBased on observations of the Environment, review of facility documentation, review of facility policy and staff interviews, the facility failed to ensure toilets in 2 shower rooms were maintained in a safe manner and the facility failed failed to ensure a safe and sanitary environment to promote a home like environment and for 1 of 8 residents reviewed for the environment for (Resident #79), the facility failed to maintain a homelike environment by ensuring the resident bathroom was free of holes and peeling paint and for 1 sampled resident ( Resident # 193), the facility failed to ensure the resident's personal clothing was labeled according to facility practice and not missing.

Inspectors wroteBased on observations, review of facility policy, facility documentation and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment and for 1 of 2 showers, the facility failed to ensure that sharp containers were emptied to ensure a safe environment.

Inspectors wroteBased on clinical record reviews, resident interview, observations and staff interviews for 1 of 6 residents ( Resident # 133) reviewed for respiratory care, the facility failed to ensure that call bells were answered timely and for 1 of 5 residents reviewed for Choices ( Resident # 140), the facility failed to ensure the call bell was accessible to the resident.

Inspectors wroteBased on clinical record review, facility policy review and interviews for 1 resident (Resident #12) reviewed for dental, the facility failed to ensure a comprehensive care plan was developed.

Inspectors wroteBased on clinical record reviews, review of facility policy and interviews for 1 of 1 resident ( Resident # 12) reviewed for dental and 2 of 4 residents (Residents # 25 and # 460 reviewed for abuse, the facility failed to revise the residents care plan timely.

Inspectors wroteBased on observations, clinical record reviews, facility policy and interviews for and 3 of 6 residents reviewed for Respiratory Care( Residents.#65, #69, and #129), the facility failed to ensure oxygen supplies were stored and tabled properly and for 1 of 6 residents reviewed for Respiratory Care (Resident #196), the facility failed to provide tracheal suctioning in accordance with professional standards.

Inspectors wroteBased on observation, review of facility policy and staff interviews for 1 of 1 resident reviewed for tracheostomy care (Resident #196), the facility failed to ensure staff were competent in providing tracheal suctioning.

Inspectors wroteBased on the tour of the kitchen, observations and staff interviews, the facility failed to ensure food storage equipment was free of hard black matter and food was stored in an organized manner and the facility failed to ensure staff applied a beard guard while preparing food.

Inspectors wroteBased on clinical record review, observations and staff interviews for 1 of 1 resident reviewed for tracheostomy care (Resident #196), the facility failed to ensure that staff used appropriate Personal Protective Equipment (PPE) when providing tracheal suctioning and failed to ensure linen was stored in sanitary manner.

Inspectors wroteBased on review of facility documents and interviews, the facility failed to ensure the Medical Director attended the monthly QAPI meetings for the years of 2022, 2023 and 2024.

Inspectors wroteBased on review of facility documentation and staff interviews for 1 of 3 residents (Resident #40) reviewed for Beneficiary Notification, the facility failed to ensure the notification was received by the responsible party timely to ensure the responsible party was aware of his/her rights.

Inspectors wroteBased on clinical record review, facility documentation, observations and interviews, for two (2) of six (6) residents reviewed for resident rights (Resident #1 and Resident #2), the facility failed to ensure that language used within close proximity of residents was appropriate.

Inspectors wroteBased on review of the clinical record review, facility documentation, facility policy and interviews for one (1) of four (4) residents (Resident #4) reviewed for abuse, the facility failed to ensure the residents were free from physical abuse within the facility.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Resident #2) who had a history of substance abuse, the facility failed to ensure the resident's rights regarding a leave of absence, a urine screen upon return from a leave of absence, restriction of visitors and by making a leave of absence contingent on identified behaviors were not violated.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for two of two sampled residents (Resident #2) who had a history of substance abuse, the facility failed to ensure the resident's rights was not violated by searching the resident's room for suspected contraband because Resident #2 had tested positive for cocaine on a urine toxicology test.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was removed from the facility by the local authorities, the facility failed to issue a thirty (30) day discharge notice.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was removed from the facility by the local authorities, the facility failed to permit the resident to return to the facility after the resident received medical treatment in a hospital and was ready for discharge to a long-term care facility.

Inspectors wroteBased on a review of facility documentation and interviews, the facility failed to honor resident rights by the exclusion of specific information in the facility leave of absence policy.

Inspectors wroteBased on observations, review of facility documentation and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one sampled resident (Resident #1) reviewed for pressure wounds, the facility failed to ensure a comprehensive care plan for a resident with refusals of care.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for nutrition, the facility failed to ensure a reweight was obtained timely for a resident and failed to ensure the dietician and physician were notified timely of a significant weight loss.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for nutrition, the facility failed to ensure the clinical record was complete and accurate to include accurate treatment documentation, and failed to ensure medical record access was maintained to ensure records were available timely.

Inspectors wroteBased on observations, interviews and review of facility documentation for 1 of 13 rooms on the 2A unit (room [ROOM NUMBER]) and for 2 of 13 rooms on the 2 B unit (room [ROOM NUMBER] and #224), for 1 of 15 rooms on the 4 A unit (room [ROOM NUMBER]), and for 1 of 13 rooms on the 4 B unit (room [ROOM NUMBER]), the facility failed to ensure the residents' rooms and furnishings were maintained in a clean, safe, homelike and sanitary manner and in good repair.

Inspectors wroteBased on observations, staff interviews and review of facility policy, the facility failed to ensure dishware and utensils were cleaned and sanitized according to facility policy and manufacture's recommendations.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and procedures and interviews for two of three residents (Resident #18 and Resident #118) reviewed for activities of daily living (ADLs), the facility failed to ensure care and services were provided to maintain good grooming or personal hygiene.

Inspectors wroteBased on observations, review of the clinical record, facility policy/procedures and interviews for one of three residents (Resident #18) reviewed for activities of daily living (ADLs), the facility failed to ensure care/treatment to Resident #18's swollen hand joint/hand contracture was completed.

Inspectors wroteBased on observation, review of facility documentation and interviews, the facility failed to maintain the dumpster and compactor area in a clean and sanitary manner.

Inspectors wroteBased on review of the clinical record, facility policy and procedures and interviews for 1 of 4 residents reviewed (Resident #18) for activities of daily living (ADLs) and for 2 of 4 (Resident #70 and Resident #91) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure the coding of the MDS assessment information was accurate.

Inspectors wroteBased on clinical record review, review of facility documentation and staff interview for one sampled resident (Resident #123) approved for short term, 60 days convalescent stay, the facility failed to apply for Level II Preadmission Screening and Resident Review (PASRR) when Resident #123 required more than the 60 day stay.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #25) reviewed for Resident Care Planning (RCP), the facility failed to invite and include Resident #25 in the RCP process.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one of two sampled residents (Resident #70) reviewed for abuse, the facility failed to ensure timely physician notification of an injury of unknown origin and/or for one sampled resident (Resident #175) reviewed for edema, the facility failed to ensure a significant weight gain was reported to the Physician/Advanced Practice Registered Nurse (APRN) and/or a significant change in condition was reported to the Physician/APRN.

Inspectors wroteBased on observation, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident #66) reviewed for cleanliness of environment, the facility failed to maintain the cleanliness of Resident #66's customized wheelchair (CWC).

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #33 and 70) reviewed for abuse, the facility failed to ensure an injury of unknown origin was reported to the state agency in a timely manner.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #33 and #70) reviewed for abuse, the facility failed to ensure an injury of unknown origin was investigated in a timely manner.

Inspectors wroteBased on review of the clinical record, review of facility documentation and interviews, for one of four residents reviewed for Pre-admission Screening and Resident Review (PASRR), (Resident #208), the facility failed to request an extension for medical needs and/or failed submit a referral for a level II assessment in a timely manner.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident # 41) reviewed for quality of care, the facility failed to follow a physician's order and/or one sampled resident (Resident #175) reviewed for edema, the facility failed to ensure a resident's weight was monitored per the physician's order.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of five sampled resident (Resident # 72) reviewed for falls, the facility failed to ensure the necessary services were provided to prevent an accident.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident, (Resident #144) reviewed for an indwelling urinary catheter, the facility failed to consistently monitor daily urinary output and/or notify the physician that the urinary catheter was not changed as ordered.

Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 1 of 6 residents (Resident #41) reviewed for unnecessary medications, the facility failed to monitor orthostatic blood pressures per physician's orders.

Inspectors wroteBased on review of the clinical record, review of facility policy and procedures, and interviews for one of five residents reviewed for unnecessary medications (Resident #109), the facility failed to document targeted behaviors for the purpose of monitoring behavioral symptoms.

Inspectors wroteBased on observation, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #66) reviewed for dental, the facility failed to follow up on denture appointments in a timely manner.

Inspectors wroteBased on observation, interviews, and review of documentation, for one resident (Resident # 139) the facility failed to maintain mechanical wheelchair in safe operating condition.