Chelsea Place

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 12/10/24. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 12/10/24. A deficiency was cited. Based on observation, record review, and interview, the residence failed to maintain a fall management program which included detailing in each resident' s care plan the individualized approaches necessary to address fall risks, affecting three of three sample residents (#3-#5) who required individualized approaches.Findings include:1. ObservationOn 12/10/24, Resident #5 was seated in a high back wheelchair.2. Record ReviewThe resident face sheet read Resident #5 was admitted to the residence on 2/20/23.A progress note, dated 9/22/24, read the resident had an unwitnessed fall and was found sitting on the floor beside her bed.A progress note, dated 9/28/24, read the resident had an unwitnessed fall near the lobby door.A progress note, dated 10/3/24, read the resident was sitting on a chair and slid to the floor.A progress note, dated 10/7/24, read late entry: the resident had a witnessed fall in the hallway. A progress note, dated 10/9/24, read the resident care plan had been updated with fall interventions after falls on 10/3/24 and 10/6/24. However there was no evidence the care plan had been updated. A progress note, dated 10/25/24, read the resident care plan had been updated with fall interventions after fall on 10/18. However, there was no evidence the residence updated the care plan or documented in a progress note that the residence sustained .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both.9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the ass..

A licensure complaint, prompted by #CO31466, was completed on 7/25/23. A deficiency was cited. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#2, #5, #6). 1. Residence Policy The residence' s Medication Refill policy, dated May 2017, read in part; "Medication refills will be obtained in a timely manner to ensure residents have all physician (practitioner) ordered medications available ... Medications are never allowed to run out unless directed to by the physician ..."The residence' s Medications are Permanently Discontinued policy, dated May 2017, read in part; "Permanently discontinued medication will not be retained in the community (residence) ..." 2. Resident #5 was admitted to the residence on 2/16/23 with diagnoses that included unspecified dementia, depression and hip fracture. a. Acetaminophen A written practitioner' s order, dated 2/15/23, directed the residence to administer Acetaminophen 500 mg three times daily. However, the July 2023 medication administration record (MAR) read the medication had not been administered as ordered for the morning dose on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.b. Senexon PlusA written practitioner' s order, dated 2/15/23 , directed the residence to administer senexon plus 8.6-50 mg one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.c. Sertraline A written practitioner' s order, dated 2/15/23, directed the residence to administer sertraline 50 mg one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.d. Spiriva A written practitioner' s order, dated 2/15/23, directed the residence to administer spiriva 2.5 mcg two puffs once daily. However, the July 2023 MAR read the medication had n..

A licensure complaint, prompted by #CO30250, was completed on 2/22/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to ensure residents had freedom of movement to their personal spaces, affecting three of three residents (#1, #2, #6) whose personal bedrooms were locked, though they did not have a key to the room. (Cross-reference Q2960)Findings include: 1. ObservationsOn 2/21 and 2/22/23 throughout the day, the doors to Residents #1, #2 and #6' s rooms were locked when the residents were not in the rooms. 2. Resident #1 was admitted to the residence on 1/20/22 with diagnoses including Alzheimer' s disease and cognitive communication deficit. The record for Resident #1 contained a document titled "Service Agreement" that h.. Based on observation, record review and interview, the residence failed to ensure residents in a secure environment had an enhanced care plan that contained the required information, affecting six of six sample residents (#1-#6). (Cross-reference Q3030) Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs.2. Resident #1 was admitted to the residence' s secure environment on 1/20/22.Resident #1' s record contained .. Based on observation, record review and interview, the residence failed to provide personal services, including a system for identifying and reporting resident concerns that required an immediate individualized approach and/or on-going monitoring, affecting two of two sample residents (#5, #6) who used oxygen. Findings include: 1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health and safety. As used in this Chapter 7, activities of daily living include, but are not limited to, accompaniment, eating, dressing, gro.. Based on record review and interview, the residence failed to ensure resident records contained progress notes that included information on resident status, as well as documentation regarding any out of the ordinary events or issues that affected residents' condition, and that staff documented progress notes before the end of their shifts, affecting four of five sample residents (#3-#5, #7). Findings include: 1. Residence PolicyThe residence' s Narrative Charting Entries policy, dated 5/20/22, read in part: "Enter all essential facts related to resident status ... State the actions/interventions made in response to the data ... Follow up and document the resident' s response to the action .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population.12.10 Each resident care plan shall:(A) Be develo..