Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Massachusetts Veterans Home At Chelsea during CMS and state inspections, most recent first.
A resident with cerebral infarction, DM, depression, and cognitive impairment had orders and a care plan for a left palmar guard and a buddy loop splint to the right 4th and 5th digits, but staff did not consistently apply the devices. Surveyors repeatedly observed the resident without either device, and staff interviews confirmed the resident often was not wearing them and that nursing was expected to apply them.
A resident with severe cognitive impairment and a history of falls was found in bed without ordered fall mats, despite a physician order and repeated observations showing no mats in place. Another resident who required supervision while smoking had cigarettes and lighters kept in the room even though the safe smoking assessment said staff must maintain the smoking materials. A third cognitively intact resident had more than 50 half-burned cigarettes, ash, and lighters stored on the desk and bedside table, and the record did not show re-evaluation of smoking safety after two smoking citations.
Unlocked bedside storage of resident supplement: A resident with quadriplegia and intact cognition had three bottles of Neuriva capsules observed on the bedside table even though the nurse administered the medication and there was no written order for bedside storage. Staff confirmed the bottles were kept at bedside, and the DON stated the supplement should have been locked in the medication cart rather than stored unlocked at the bedside.
A resident with dementia and diabetes, known for being resistant to care, was physically restrained by a nurse laying across their lap and legs during a podiatry procedure. The resident verbally objected and requested the care to stop, but staff continued to hold the resident's hands and limit movement, contrary to facility policy requiring IDT assessment before restraint use. Multiple staff confirmed the resident's agitation and the use of restraint during the procedure.
A resident with cognitive impairment and diabetes, who was known to be combative and resist care, was subjected to foot care by staff despite verbal refusal and combative behavior. Staff did not follow the care plan intervention to reapproach later and instead continued with the care due to the podiatrist's presence, leading to a deficiency in implementing person-centered care.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident did not receive heel protector booties as ordered by a physician, and staff were unaware of the order. Another resident's care plan did not include management for a pacemaker, and staff were unaware of the device and necessary follow-up appointments.
A facility failed to obtain pending lab results for a resident discharged from the hospital, who had diagnoses including dementia, diabetes, and weight loss. The medical record lacked evidence of acquiring the lab results for Legionella, and there was no documentation of communication with the hospital or notification to the physician. Interviews revealed that the nurse was unaware of the pending lab, and the Superintendent of Operations stated it was expected for the nurse to follow up with the hospital.
A resident with moderately impaired cognition and psychiatric disorders eloped twice from the facility due to inadequate assessment and supervision. The resident's key card access was initially granted based on physical capability assessments, without considering cognitive ability, influenced by the health care proxy's insistence. A care plan addressing elopement risk was delayed, and facility policy for managing cognitively impaired residents was not effectively implemented.
The facility failed to create trauma-informed care plans for two residents with PTSD. One resident, with a history of physical abuse, had no PTSD assessment or care plan addressing triggers. Another resident's care plan lacked specific PTSD triggers despite an assessment identifying them. The responsible social worker acknowledged the oversight.
A facility failed to notify a physician of a dentist's recommendation for a resident with dementia, diabetes, and cancer. The dentist recommended Peridex mouth rinse, but the physician's orders from July to October did not include it. Nursing notes did not show acknowledgment or notification to the physician, and the physician's notes lacked entries after early July. The Deputy Superintendent expected nursing to inform the physician and document the response, but no policy was found for this process.
A resident with a history of major depressive disorder and suicidal ideation did not receive appropriate behavioral health services at the facility. Despite recommendations for mental health visits and psychiatric follow-ups, the facility failed to document or provide these services. The resident experienced worsening depression and was repeatedly sent to the hospital for psychiatric evaluations, but no behavioral health services were implemented upon their return. Interviews revealed inconsistencies in therapy and logistical issues preventing psychiatric hospital admission.
The facility failed to secure medications properly for two residents. One resident, with legal blindness and moderate cognitive impairment, had pills left at the bedside by a nurse. Another resident, cognitively intact but not assessed for self-administration, had Lidocaine patches left unattended. Facility policy requires medications to be secure and under constant surveillance unless specific conditions are met.
A resident in a LTC facility felt uncomfortable and lost trust in staff after a nurse and CNA argued in their room while providing care. The resident, who required assistance due to paraplegia and other conditions, filed a grievance about the unprofessional behavior. Both staff members acknowledged the disrespectful nature of their actions.
A resident with moderate cognitive impairment and behavioral disturbances was subjected to abuse by staff members in two separate incidents. In the first incident, a CNA engaged in a verbal altercation with the resident, leading to the resident punching the CNA, who then threw an object at the resident. In the second incident, another CNA was intimidating and confrontational, escalating the resident's agitation. The facility's policies on abuse and behavior management were not followed, resulting in the resident's exposure to abuse.
A facility failed to report an allegation of verbal abuse within the required timeframe. A housekeeper reported that a CNA called a resident an idiot. The incident was reported to the Administrator, who instructed the Quality Nurse Manager to submit the report to DPH within two hours. However, the report was submitted seven days later due to an error.
Failure to Consistently Apply Ordered Splints and Palm Guard
Penalty
Summary
The facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for one resident with cerebral infarction, diabetes, depression, moderate cognitive impairment, and upper body range of motion impairment. The resident had physician orders for a left palmar guard to be applied at 9:00 P.M. and removed at 9:00 A.M., with daily skin checks, and for a buddy loop finger splint to the right 4th and 5th digits to be applied every shift and kept on at all times except during daily skin assessment and ADL care. The care plan also directed nursing to apply the left palmar guard overnight and the right buddy loop splint to the right D4 and D5 fingers. During interviews and observations, the resident stated staff do not always remember to apply the palm guard and that he/she needs to remind them. Surveyors repeatedly observed the resident without the left palm guard and without the right finger buddy loop on multiple occasions across several days. A CNA stated the resident had not used the right-hand loop buddy in a while, and a nurse stated the resident wears something on the 4th and 5th fingers sometimes and takes it off, requiring staff encouragement; the nurse also stated the resident does not wear any devices on the left hand. The OT said nursing should be offering and applying both devices, while the VCC reviewed documentation and could not find support that nursing was applying the left palm guard. The DON stated nursing should implement the resident's plan of care for contracture management and apply both devices.
Unsafe handling of fall protection and smoking materials
Penalty
Summary
The facility failed to maintain a safe environment for three sampled residents related to falls and smoking materials. For one resident with Huntington's disease, hypotension, severe cognitive impairment, dependence on staff for transfers and bed mobility, and a recent fall with injury, the physician ordered bilateral fall mats beside the bed at bedtime. Survey observations on multiple days found the resident in bed without fall mats on either side, and staff members, including CNAs, a nurse, the VCC, and the DON, stated that the resident did not use fall mats. The VCC also reviewed the electronic record and said nursing was documenting fall mats as implemented during the day shift, but no mats were found in the room. For another resident with nicotine dependency who was cognitively intact and actively used tobacco, the facility's safe smoking assessment indicated the resident could not maintain his/her own smoking materials and had to request them from staff and be supervised while smoking. Despite this, cigarettes and lighters were observed in the resident's room on the bedside table during survey observations. Staff gave conflicting statements about whether the resident could keep smoking materials in the room, while the nurse and DON stated that the resident required the nurse to lock up the smoking materials and should not have them in the room. The ADL fact sheet documented escorting the resident outside to smoke, but did not clearly reflect the restriction on maintaining smoking materials. For a third resident with diabetes and a history of substance abuse who was cognitively intact, surveyors observed more than 50 half-burned cigarettes stored directly on the desk with ash-like residue, along with two clear plastic bottles filled with half-burned cigarettes and two lighters on the bedside table. Staff members stated that the resident managed his/her own smoking materials and that they had not notified anyone about how the items were stored. The resident reported having received multiple smoking citations from security, and the facility's public safety smoking citation report documented two citations. The record did not show that the resident's ability to smoke and manage smoking materials was re-evaluated after the citations, and the morning meeting matrix did not show the citations or storage concerns were discussed.
Unlocked bedside storage of resident supplement
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for one resident out of a 25-resident sample. Resident #65, who was admitted in January 2024 with diagnoses including quadriplegia and had a BIMS score of 15 out of 15 on the most recent MDS, had three bottles of Neuriva capsules observed on the bedside table during surveyor observations. The resident stated that the nurse administers the Neuriva capsules and that the resident does not self-administer because of quadriplegia. Review of the resident’s physician’s order showed an order to give one Neuriva capsule by mouth daily and that the resident may take own supply not supplied by pharmacy, but there was no written order for bedside storage. The MAR and care plan also did not indicate bedside storage for Neuriva. CNA #8, CNA #9, and Nurse #5 confirmed that the bottles were kept on the bedside table, and Nurse #5 stated the resident did not have an order to store the capsules at bedside. The DON stated the order meant the resident could order the medication, but it should be locked in the medication cart and labeled with the resident’s name, and that the Neuriva capsules should not have been stored unlocked at bedside.
Resident Restrained During Podiatry Care Without Proper Assessment
Penalty
Summary
A resident with significant cognitive impairment, dementia, and diabetes was subjected to physical restraint during a podiatry care session. The facility's policy required that physical restraints only be used after assessment by the Interdisciplinary Team (IDT) and when alternatives had been deemed ineffective, but this process was not followed. The Charge Nurse made the unilateral decision to proceed with podiatry care despite the resident's history of resistance and recent refusals of such care. During the procedure, the Charge Nurse laid across the resident's lap and legs to prevent movement, while a Certified Occupational Therapy Assistant (COTA) and a Certified Nurse Aide (CNA) held the resident's hands. The resident verbally expressed refusal and distress multiple times, requesting for the care to stop and to be left alone. Staff interviews confirmed that the resident was agitated, combative, and verbally objected to the care, yet the procedure continued with physical restraint. The COTA reported feeling uncomfortable with the method used, as it limited the resident's mobility, and stated he would not have participated had he known restraint was being used as the only means to complete the care. The Charge Nurse later acknowledged that her approach was inappropriate and that the situation should have been handled differently, such as consulting a physician for alternative arrangements. The incident was reported internally and confirmed by multiple staff members.
Failure to Follow Care Plan Interventions for Resident Refusing Care
Penalty
Summary
Staff failed to consistently implement care plan interventions for a resident with a history of combativeness and resistance to care. The resident, who had significant cognitive impairment, dementia, and diabetes, was care planned to allow refusal of care, with instructions for staff to maintain safety and reapproach at a later time if care was refused. On one occasion, despite the resident verbally refusing foot care and displaying combative behavior, staff continued with the care instead of following the intervention to reapproach later. The care plan also indicated that staff should not force care and should notify the provider if the resident refused. Interviews with facility staff confirmed that the charge nurse was aware of the resident's refusal and the care plan interventions but proceeded with the care due to the presence of the podiatrist and time constraints. The assistant director of nursing acknowledged that the charge nurse should not have forced the resident to accept treatment and should have sought assistance from leadership for alternative care. The failure to follow the established care plan interventions resulted in the deficiency.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. For Resident #30, who was admitted with diagnoses including diabetes mellitus, hemiplegia, and peripheral vascular disease, the facility did not follow the physician's order to apply heel protector booties while the resident was in bed. Despite the resident being at risk for skin breakdown and having a physician's order dated 9/30/24 for heel protectors, the order was not transcribed onto the Treatment Administration Record (TAR), and staff did not offer the heel protectors to the resident. Observations on 10/7/24 and 10/8/24 confirmed that the resident was not wearing the booties, and interviews with staff revealed a lack of awareness about the order. For Resident #264, who was admitted with diagnoses including dementia, diabetes, and weight loss, the facility failed to develop a care plan for the resident's pacemaker. The hospital discharge report indicated that the resident had a single chamber Medtronic pacemaker implanted, but the current care plan, nursing progress notes, physician's orders, and treatment administration records did not reflect this. Interviews with staff indicated a lack of awareness about the resident's pacemaker and the need for follow-up appointments, highlighting a significant oversight in the resident's care management.
Failure to Obtain Pending Lab Results for Resident
Penalty
Summary
The facility failed to follow standards of practice by not obtaining lab results for a resident who was discharged from the hospital with pending labs. The resident, admitted in February 2024, had diagnoses including dementia, diabetes, and weight loss. A review of the medical record showed no indication that the facility acquired the pending lab results for Legionella, as noted in the hospital document dated 9/27/24. Additionally, nursing progress notes did not show any attempt to contact the hospital for these results, nor did physician progress notes indicate that the physician was informed of the pending labs. During interviews, Nurse #1 was unaware of the pending lab result from the resident's hospital discharge on 9/27/24. The Superintendent of Operations confirmed that it was expected for the nurse to call the hospital for pending lab results upon the resident's discharge.
Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #40, who was at risk of elopement. Resident #40, admitted with psychiatric disorder and depression, had moderately impaired cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Despite this, the resident was initially assessed as not at risk of elopement. However, on two occasions, the resident managed to leave the facility premises. The first incident occurred when the resident left the campus in a wheelchair and was unable to return, requiring assistance from a good Samaritan and emergency services. The second incident involved the resident eloping from a locked unit due to a broken employee entrance door. The facility's policy for managing residents who are cognitively impaired and at risk of wandering or elopement was not effectively implemented. The resident's key card access, which allowed them to leave the facility, was revoked only after the first elopement incident. A care plan addressing the resident's elopement risk was developed two months after the initial incident. Interviews with facility staff revealed a lack of communication and assessment regarding the resident's cognitive ability to safely navigate outside. The physical therapist assessed the resident's physical capabilities but did not evaluate cognitive abilities, and the health care proxy's insistence on key card access influenced the decision, despite concerns about the resident's mental health status.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed plan of care for two residents diagnosed with PTSD. Resident #109, admitted in August 2024, had a diagnosis of PTSD due to physical abuse from a parent. Despite having intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not include a trauma-informed approach or a PTSD assessment. During an interview, Social Worker #1 acknowledged that a PTSD care plan should have been developed, including identifying and managing PTSD triggers. Similarly, Resident #92, admitted in March 2024 with PTSD, bipolar depression, and kidney disease, did not have a comprehensive care plan that included specific PTSD triggers. Although a behavioral assessment identified triggers such as overstimulation and not understanding expectations, these were not incorporated into the care plan. Social Worker #1, responsible for Resident #92, admitted to not including the individualized triggers in the care plan, despite recognizing the need to do so.
Failure to Notify Physician of Dental Recommendation
Penalty
Summary
The facility failed to ensure that a physician was notified of a recommendation from a consulting dentist for a resident. The resident, who was admitted in February 2024 with diagnoses including dementia, diabetes, and cancer, had a dental consult on July 15, 2024, which recommended the use of Peridex mouth rinse twice daily. However, a review of the physician's orders from July to October 2024 did not include an order for the Peridex mouth rinse. Additionally, nursing progress notes after July 14, 2024, did not indicate any acknowledgment or notification to the physician regarding the dentist's recommendation. The physician's progress notes also lacked any entry after July 12, 2024. During an interview, the Deputy Superintendent expressed that nursing should have informed the physician of the dentist's recommendation and documented the physician's response, but no policy or procedure was found regarding this notification process.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide appropriate behavioral health services for a resident with a history of major depressive disorder and suicidal ideation. The resident was admitted with psychiatric disorders and depression, and their care plan included interventions for suicidal ideation, such as calling a clinician or social worker for evaluation and referring to mental health services. Despite these measures, the facility did not document any behavioral health services provided to the resident after their re-admission following a hospital discharge for expressing suicidal ideation. The resident experienced worsening depression and was recommended for a mental health visit and psychiatric follow-up, but the record did not indicate that these services were provided. The resident was sent to the hospital for psychiatric evaluation multiple times, yet the facility failed to implement any behavioral health services after these admissions. The resident continued to experience increased anxiety and behavioral disturbances, leading to further emergency department visits. Interviews with facility staff revealed that the resident was supposed to be sent to a psychiatric hospital, but logistical issues prevented this from happening. The social worker acknowledged that the resident's therapy at the VA was inconsistent and that there was no individual therapist available since May or June. The facility's administration was uncertain about obtaining therapy information from the VA, and the Deputy Superintendent recognized the facility's responsibility to ensure residents receive necessary mental health care.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that prescribed medications were secured in locked compartments or under proper supervision for two residents. For one resident, who was admitted with diagnoses including legal blindness and osteoarthritis, the nurse left two pills at the bedside without proper supervision. This resident had a moderate cognitive impairment and was not assessed to be safe to self-administer medications. The facility's policy required that medications be kept secure and under constant surveillance, and that medications should not be left unattended unless the resident was assessed to be safe for self-administration and had a physician's order. For another resident, who was admitted with diagnoses including hypertension and back pain, the nurse left topical prescription medication, specifically Lidocaine patches, at the bedside without proper supervision. This resident was cognitively intact but was not assessed to self-administer medications or have medications stored bedside. The facility's policy indicated that no medications should be left at the bedside unless the resident was assessed for the ability to self-administer the specific medication and had a physician's order to store the specific medication at bedside. Interviews with nursing staff and the Director of Nursing confirmed that the medications should not have been left unattended.
Staff Argument in Resident's Room Breaches Respect and Dignity
Penalty
Summary
The facility failed to ensure that staff treated a cognitively intact resident with respect and dignity. On the evening shift of June 21, 2024, a nurse and a certified nurse aide (CNA) were involved in an argument in the hallway outside the resident's room. They continued their disagreement inside the resident's room while providing care, which made the resident feel uncomfortable. The resident, who was admitted in February 2024 with diagnoses including paraplegia and neurogenic bladder/bowel, required assistance from two staff members for care and was able to communicate needs and make decisions independently. The resident filed a grievance, expressing discomfort and a loss of trust in the staff due to the unprofessional behavior exhibited by the nurse and CNA. During interviews, the resident described the situation as disrespectful, particularly noting the lack of respect for personal space. The nurse admitted to discussing the break schedule in the resident's room, acknowledging it was disrespectful, while the CNA confirmed the argument's continuation in the room despite attempts to avoid further discussion. The interim Director of Nursing (DON) confirmed the resident's report of feeling uncomfortable due to the staff's behavior.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident with moderate cognitive impairment and a history of behaviors from abuse by staff members. On one occasion, a Certified Nurse Aide (CNA) engaged in a verbal altercation with the resident, which escalated to the resident punching the CNA. In response, the CNA threw an object at the resident, which did not hit them. The facility's policy on abuse, which includes verbal and physical abuse, was not adhered to, as the CNA did not attempt to de-escalate the situation or walk away. In a separate incident, another CNA engaged in a verbal altercation with the same resident, which led to the resident becoming agitated. The CNA was observed to be intimidating and confrontational, gesturing with a napkin holder towards the resident. This behavior further escalated the resident's agitation, and staff had to intervene to separate them. The facility's policy on maintaining a comfortable environment and using therapeutic communication was not followed, contributing to the escalation of the resident's behaviors. The resident involved in these incidents had a history of dementia with behavioral disturbances and required assistance with activities of daily living. Despite this, the staff's actions did not align with the resident's behavior care plan, which included interventions to manage verbal behaviors and agitation. The failure to implement these interventions and adhere to the facility's abuse policy resulted in the resident being subjected to abuse by staff members.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required timeframe. A housekeeper reported to the Housekeeping Supervisor that a Certified Nurse Aide (CNA) called a resident an idiot after the resident repeatedly asked to go outside to smoke. The Housekeeping Supervisor immediately notified the Nursing Supervisor, who then identified the CNA and suspended her employment. The incident was reported to the Administrator, who instructed the Quality Nurse Manager to submit the report to the Department of Public Health (DPH) within two hours. However, the Quality Nurse Manager failed to submit the report immediately due to an error and only submitted it seven days later. The resident involved had diagnoses of alcohol abuse and dementia with behavioral issues, and their medical record indicated severely impaired cognition and behavioral symptoms not directed toward others. The facility's policy required that allegations of abuse be reported to the state agency within two hours, but the report was not submitted until seven days after the administrative staff became aware of the incident. This delay in reporting was discovered when the Administrator realized the report had not been submitted as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chelsea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katzman Family Center For Living | 0.2 mi | ★★★★★ | 5 | 0 |
| Rehabilitation & Nursing Center At Everett (the) | 0.9 mi | ★★★★★ | 12 | 0 |
| Highland Park Rehabilitation And Healthcare Center | 1 mi | ★★★★★ | 21 | 0 |
| Leonard Florence Center For Living | 1 mi | ★★★★★ | 2 | 0 |
| Lighthouse Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 7 | 0 |
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