Chelsea Place Care Center LLC

In the surveyor’s words

From the most serious findings on record at Chelsea Place Care Center LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 5, 2026

  Based 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… […]

• Actual harm, isolatedF657Jun 21, 2021

  Based on clinical record reviews, observations, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was reviewed for a comprehensive plan of care, the facility failed to revise the resident's plan of care and implement a level of supervision to protect the resident when the resident consistently expressed a desire for discharge against the wishes of the conservator. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#1's clinical record identified Person #1 as R#1's conservator. A Resident Care Plan (RCP) dated [DATE] identified R#1's desire to be discharged from the facility to community-based living. […]

• Actual harm, isolatedF689Jun 21, 2021

  Based on clinical record reviews, observations, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was reviewed for care planning, the facility failed to ensure the resident was not able to exit through a window when the resident broke the window stoppers, removed the window and climbed out the forth floor window and was found deceased on the ground. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses that included paranoid [CONDITION(S)] and anxiety. A review of R#1's clinical record identified Person #1 as R#1's conservator. A Resident Care Plan (RCP) dated [DATE] identified R#1's desire to be discharged from the facility to community-based living. […]

• No harm, potential for more than minimal, widespreadF923Aug 18, 2026

  Based on observations and interviews, the facility failed to ensure the facility had adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. The findings include:Observations of the facility on all days of the survey 8/11, 8/12, 8/13, 8/17 and 8/18/26 identified 4 floors to the facility. Entry to the facility on the 1st floor containing administration and nursing offices and a large recreation room. Resident rooms were present on the 2nd, 3rd and 4th floors of the facility. All resident rooms on the 2nd, 3rd and 4th floors of the facility had screws in the windows that prevented them from being opened at all. Some of the windows did not have screens in them. […]

• No harm, potential for more than minimal, patternF658Aug 18, 2026

  Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 4 of 9 sampled residents (Residents #9, #87, #162 and #216)) reviewed for medication administration, the facility failed to ensure that the methadone orders in the clinical record matched the orders from the methadone clinic who supplies the bottled methadone being administered to the residents, and failed to ensure suboxone administration was conducted according to professional standards. […]