The Massachusetts Veterans Home at Chelsea

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for one Resident (#29) out of 25 total sampled residents. Specifically, for Resident #29, nursing failed to consistently implement the Resident's left hand palm guard and buddy loop finger splint to his/her right 4th and 5th digits (fingers).

Inspectors wroteBased on observations, interviews, policy review and record review, the facility failed to maintain a safe environment for three Residents (#31, #52, and #45) out of 25 total sampled residents. Specifically,1.) for Resident #31, the facility failed to provide fall mats in accordance with the physician's order. 2a.) For Resident #52, the facility failed to ensure staff stored the Resident's smoking materials in a locked area.2b.) For Resident #45, the facility failed to re-evaluate Resident's ability to safely maintain his/her own smoking materials after staff noted half burned cigarettes stored directly on his/her desk and was issued two smoking violations.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for one Resident (#65) out of a 25 total sampled residents. Specifically, the facility failed to ensure Resident #65's neuriva capsules (a brain health supplement) were not stored unlocked at bedside.

Inspectors wroteBased on records reviewed and interview, for one of three sampled residents, (Resident #1) who had a history of being resistant and combative during care, the facility failed to ensure he/she was free from the use of physical restraint, when on 6/17/25, while Resident #1 was receiving foot care from the podiatrist, the Charge Nurse laid across his/her lap/leg area to prevent him/her from moving during the procedure.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who had a history of combativeness and resistance with care, the Facility failed to ensure staff consistently implemented interventions identified in his/her plan of care, which indicated when Resident #1 refused care that staff shouldn't force him/her, but instead should reapproach him/her when he/she is more accepting of care. On 06/17/25, although Resident #1 told staff to leave his/her feet alone, exhibited combative behavior during foot care, staff continued with care and did not implement interventions to return later.

Inspectors wroteBased on observation, interview, and record review for two Residents (#30, #264) out of 26 sampled residents, the facility failed to implement the plan of care. Specifically: 1. For Resident #30, the facility failed to follow the physician's order to apply heel protector booties. 2. For Resident #264, the facility failed to develop a plan of care for a pacemaker.

Inspectors wroteBased on record review and interview the facility failed to ensure they followed standards of practice for 1 Resident (#264) out of a total sample of 26 residents. Specifically the facility failed to obtain lab results for a lab obtained during a hospitalization which was still pending upon discharge of the Resident from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#40) was safe from accidents/hazards out of a total sample of 26 residents. Specifically, the facility failed to appropriately assess the Resident for safety and ensure a safety care plan was developed to prevent an elopement.

Inspectors wroteBased on record review and interview, the facility failed to develop a trauma informed plan of care for 2 Residents (#109 and 92) out of a total sample of 26 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure the physician was notified of a recommendation from a consulting dentist for one Resident (#79) out of a total sample of 26 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide appropriate behavioral health services for 1 Resident (#40) out of a total sample of 26 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure prescribed medications were secured in locked compartments or under proper supervision for two Residents (#31 and #7) out of 26 total sampled residents. Specifically: 1.) For Resident #31, the nurse left two pills at bedside without proper supervision. 2.) For Resident #7, the nurse left topical prescription medication at bedside without proper supervision.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1) who was cognitively intact, the Facility failed to ensure staff treated him/her in a respectful manner, when on 06/21/24 during the evening shift, Nurse #1 and Certified Nurse Aide (CNA) #1 were arguing in the hallway outside of Resident #1's room, they then enter his/her room to provide care, and continued their argument in front of him/her, which made him/her feel uncomfortable.

Inspectors wroteBased on records reviewed, review of surveillance camera video footage, and interviews for one of four sampled residents (Resident #2), who had moderate cognitive impairment, a history of behaviors, and was dependent on staff for care, the Facility failed to ensure he/she was free from abuse from staff members, when 1) on 6/29/24. Certified Nurse Aide (CNA) #4 engaged in a verbal altercation with Resident #2 and responded by throwing an object at him/her and 2) on 7/01/24, CNA #3 also engaged in a verbal altercation with Resident #2, was intimidating and confrontational while engaging with him/her, which resulted in escalating his/her behaviors.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have been subjected to verbal abuse by Certified Nurse Aide #1, the Facility failed to ensure they submitted a report to the Department of Public Health within the required timeframe (two hours), after being made aware of the allegation, when their report regarding the allegation was not submitted until seven days after administrative staff became aware of the allegation.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility.

Inspectors wroteBased on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (c) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

Inspectors wroteBased on record reviews and interviews, the facility 1) failed to develop a dementia care plan for one Resident (#40), 2) failed to follow physician orders for two Residents (#22 and #2) and 3) facility failed to follow a physician order to ensure air mattress was maintained at the proper setting for one Resident (#37) out of a total sample of 17 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to identify and complete a Significant Change in Status assessment, Minimum Data Set assessment (MDS) for one Resident (#32), who elected to receive hospice care services, out of a total sample of 17 residents.

Inspectors wroteBased on record review and interview the facility failed to complete an Minimum Data Set assessment for a resident discharge/return anticipated and failed to complete an MDS assessment for a resident re-entry to the facility for one Resident (#32) out of a total sample of 17 residents, resulting in inaccurate MDS data and the possible failure to care plan for Resident #32's post hospital needs.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to identify, assess and document a bruise for 1 Resident (#30) out of a total sample of 17 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications once opened were dated as required on 1 of 3 sampled medication carts.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide dental services for one Resident (#14) out of a total sample of 17 residents. Specifically, the facility failed to provide dental services to Resident #14 since admission to the facility.

Inspectors wroteBased on observation, policy and record review the facility failed to ensure infection control was maintained by 2 out of 2 nurses observed during medication pass.