Chelsea Retirement Community

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 6, 2025

  Based on observation, interview, and record review the facility failed to ensure opened food items were dated, and had a use by date in a current facility census of 83 residents.Findings Included:During the initial kitchen tour on 8/04/2025 at 9:15 AM with Dietary Director (DD) J in the [NAME] one kitchen it was observed in one of the refrigerators a bag of opened English muffins that did not have a date that the muffins were opened nor a dated that the muffins were to either be used by (UBD-use by date) or discarded. Further observation revealed that in the same refrigerator there were six loaves of opened bread that did not have the date the loaves were opened nor a UBD. […]

• No harm, potential for more than minimal, widespreadF812May 25, 2023

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 05/22/23 at 09:26 A.M., An initial tour of the main food production kitchen was conducted with Chef Manager C. The following items were noted: The South Bend conventional oven(s) exterior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend griddle and side plates were observed soiled with accumulated and encrusted food residue. The MagiKitch'n char broiler backsplash and side plates were observed with accumulated and encrusted food residue, adjacent to the two grate plates. […]

• No harm, potential for more than minimal, widespreadF725Jun 29, 2022

  This citation is related to Intake #MI 624, #MI 361, #MI 567, #MI 282. Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the needs of six sampled residents (#5, #53, #60, #66, #301 and #425), 11 confidential resident interviews, and one confidential family interview within the facility population of 74 residents. This deficient practice resulted in actual and potential avoidable episodes of incontinence, actual and potential delayed assistance for care such as transfer to bed (#310) and with walking (#66) and frustration and helplessness with call lights going unanswered and needs not being addressed. […]

• No harm, potential for more than minimal, patternF550Jun 29, 2022

  This citation pertains to intake MI 624, MI 361, and MI 567 Based on observation, interview, and record review, the facility failed to provide dignified care including timely answering of call lights and/or not providing medical supplies for five Residents (#5, #53, #60, #66, and #425) of 19 residents and six Confidential Residents reviewed for dignity and resident rights. This deficient practice resulted in feelings of frustration, helplessness, and incontinence episodes. Findings include: Resident #53 Review of Resident #53's Minimum Data Set (MDS) significant change assessment, dated 6/03/22, revealed Resident #53 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF585Jun 29, 2022

  Based on interview, and record review, the facility failed to provide an atmosphere of openness to voice concerns and grievances without reprisal and failed to act on grievances as expressed by 11 confidential residents requesting anonymity in a population of 74 facility residents. This deficient practice resulted in residents choosing not to express grievances regarding care and perceived staff shortages due to feelings of possible retaliation and resulted in a potential for unmet care needs and a lack of grievance resolution. Findings include: A confidential group meeting took place on 6/28/22 at 3:30 PM, and it was noted all the residents at the meeting stressed their strong desire to remain anonymous. […]