Chelsea Gardens

In the surveyor’s words

From the most serious findings on record at Chelsea Gardens, in the surveyor’s own words.

• Immediate jeopardy, patternF692Nov 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF656Mar 9, 2026

  Based 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… […]

• Immediate jeopardy, isolatedF689Mar 9, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Dec 9, 2021

  Based on observation, interview, and record review; it was determined the facility failed to ensure all residents were free from psychological abuse and neglect for 1 of 7 residents reviewed for neglect (CR#1). The facility failed to adhere to residents' rights/self-determination, when CR#1 refused to go to the emergency room to be checked out for an eye roll to rule out stroke or [CONDITION(S)]. The facility failed to ensure CR #1 was free from psychological abuse and retaliation. These failures placed facility residents at risk of abuse and neglect. Findings included: Record review of CR #1's face sheet dated 12/7/2021 indicated CR#1 admitted to the facility on [DATE] and was discharged on [DATE]. […]

• Immediate jeopardy, isolatedF684Dec 9, 2021

  Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1of 7 residents reviewed for quality of care. (CR#1) The facility failed to allow CR#1 back into the facility after she left from her doctor's appointment on 11/16/21 at 2PM. The resident attempted to return to the facility at 5 PM, but was denied. The facility made CR#1 sit outside in a wheelchair from 8PM until she was sent to the hospital on 11/17/21 at 2AM, during which the facility refused her access to her personal belongings, food, medications, or incontinence care. An Immediate Jeopardy (IJ) was identified on 12/1/2021 at 4:30 PM. […]