Chelsea Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Chelsea Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 12, 2024

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect a resident from abuse by another resident, resulting in harm, a fractured wrist, for one of 32 residents in the survey sample, Residents #32 and #16. The findings include: The facility synopsis of the event, dated, 3/22/24, documented, Resident to Resident, separated, abut policy initiated. Residents involved: (Resident #32 and Resident #16). The facility synopsis of the event, dated 3/29/24, documented in part, (R32) was in the dining room on the evening of March 22nd around 5:10 p.m. He was watching a program in the dining room, as he often does. When (R16) came into the dining room, he changed the TV channel without first, communicating with (R32). […]

• No harm, potential for more than minimal, patternF658Sep 12, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of 32 residents in the survey sample, Resident #19. The findings include: 1.a. For Resident #19 (R19), the facility staff failed to document progress notes in a timely manner A review of R19's clinical record revealed three progress notes related to R19 with an effective date between two to four days prior to when the note was actually written. These notes were: On 8/26/24, LPN (licensed practical nurse) #2 wrote a note about what she observed and assessed on 8/22/24. She documented this as a Late Entry. On 8/26/24, RN (registered nurse) #1 wrote a note about what she observed and assessed on 8/23/24. […]

• No harm, potential for more than minimal, patternF657Dec 13, 2022

  Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plans for three of 33 residents in the survey sample, Residents #11 (R11), #29 (R29), #30 (R30). The findings include: 1. For R11, the facility staff failed to review and revised the comprehensive care plan when psychoactive medications were discontinued. On the most recent MDS (minimum data set) assessment, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident severely cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving anti-depressants for seven days of the look back period. […]

• No harm, potential for more than minimal, patternF839Dec 13, 2022

  Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for four of five CNA (certified nursing assistants), CNA #1, CNA #2, CNA #3 and CNA #4 The findings include: The facility staff failed to provide the evidence of required certification verification prior to expiration, for four CNAs that were employed for greater than on year. During the Sufficient and Competent Staffing facility task review conducted on [DATE] at 9:30 AM the following CNA employee records and certifications were reviewed and revealed the following: 1. […]

• No harm, potential for more than minimal, isolatedF580Dec 10, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the provider of a resident's change in condition in a timely manner for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to notify the physician in a timely manner of neurological status changes after a fall. A review of R1's clinical record revealed the following progress notes: 3/31/24 at 7:50 p.m. Falls/Trauma .Altered level of consciousness .Patient initial evaluation post fall stable VS (vital signs) WNL (within normal limits). Patient c/o (complained of) pain to left side of head in area of hematoma. Neuro (neurological check) #4 pupils unequal, non-reactive. […]