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Deficiency Records for Chelsea Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Chelsea Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Chelsea Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-28 | 2023-11-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-16 | 2023-05-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-16 | 2023-02-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-13 | 2023-01-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-13 | 2023-01-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-13 | 2023-01-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-13 | 2023-01-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-13 | 2023-01-27 | N |
| Post nurse staffing information every day. | Health | 2022-12-13 | 2023-01-27 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-12-13 | 2023-01-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-13 | 2023-01-27 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-13 | 2023-01-27 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-13 | 2023-01-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-17 | 2021-09-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-17 | 2021-09-22 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-17 | 2021-09-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-17 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-17 | 2021-09-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-17 | 2021-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-09-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-08-17 | 2021-09-22 | N |
| Post nurse staffing information every day. | Health | 2021-08-17 | 2021-09-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-08-17 | 2021-09-22 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-08-23 | 2021-09-20 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-08-23 | 2021-09-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-29 | 2019-07-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-29 | 2019-07-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-29 | 2019-06-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-17 | 2019-05-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-17 | 2019-05-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-17 | 2019-05-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-17 | 2019-05-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-17 | 2019-05-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-04-17 | 2019-05-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-17 | 2019-05-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-17 | 2019-05-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-17 | 2019-05-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-17 | 2019-05-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-17 | 2019-05-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-17 | 2019-05-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-17 | 2019-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-17 | 2019-05-28 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-04-17 | 2019-05-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-17 | 2019-05-28 | N |
| Post nurse staffing information every day. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-17 | 2019-05-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-17 | 2019-05-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-17 | 2019-05-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-17 | 2019-05-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-17 | 2019-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-17 | 2019-05-28 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-17 | 2019-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-17 | 2019-05-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-17 | 2019-05-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-04-17 | 2019-05-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-04-17 | 2019-01-11 | N |
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