Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chelsea Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident on blood-thinning medications experienced a fall, resulting in a large hematoma and altered consciousness. Despite initial assessments showing stable vital signs, subsequent checks revealed unequal and non-reactive pupils, drowsiness, and nausea. The facility staff failed to notify the physician promptly, contrary to facility policy, leading to a delay in addressing the resident's condition.
A facility failed to include the risks of anticoagulant medications in a resident's baseline care plan upon admission. The resident was prescribed Aspirin and Apixaban, which increase bleeding risk, but this was not documented in the care plan. Interviews with nursing staff confirmed the omission, which violated the facility's policy requiring comprehensive baseline care plans within 48 hours of admission.
A resident on blood thinners experienced a fall, resulting in a hematoma and altered consciousness. Initial assessments showed stable vitals, but later checks revealed unequal, non-reactive pupils and drowsiness. Despite facility policy requiring immediate notification of a physician for such changes, there was a delay in contacting emergency services.
A resident in an LTC facility sustained a fractured wrist after an altercation with another resident over a TV channel change. Both residents had severe cognitive impairments and a history of traumatic brain injury. The incident was unwitnessed, and staff responded by separating the residents and assessing the situation. The facility updated care plans and provided staff education on abuse prevention following the event.
A resident's care was compromised due to the facility staff's failure to document progress notes in a timely manner and perform complete neurological assessments. Progress notes were delayed by several days, and pupil response was not recorded in any of the neurological assessments following a fall. Interviews revealed that staff were overwhelmed and facility policies lacked guidance on timely documentation and thorough assessments.
Two residents experienced a lack of dignity in their care. An LPN wrote on a dressing applied to a resident's buttock, contrary to policy, and a resident with a Foley catheter had their bag visible without a privacy cover. Both incidents were reported to the facility's administration.
A resident's call bell was not within reach, as it was found on the floor beside the roommate's bed, lacking a clip to attach it to the bed sheets. The resident expressed the need for the call bell for assistance. A nurse stated that staff should ensure call bells are clipped to bed sheets and within reach during rounds. The facility's policy did not address maintaining call bells within reach, and the issue was reported to the administrator and DON.
A resident was transferred to the hospital due to a change in condition, but the facility failed to provide written notification of the transfer to the resident's representative. The LPN notified the responsible party by phone, but the DON could not provide evidence of a written notice, as required by facility policy.
Facility staff failed to implement a comprehensive care plan for a resident with an indwelling urinary catheter. The care plan required a dignity bag or privacy cover over the urinary collection bag in social settings or when visible to others. The resident was observed without a privacy cover, and the bag was visible from the hall. A nurse confirmed the need for a privacy bag to maintain dignity, but the facility did not provide a policy on care plans.
A resident with diabetes and limited use of their hands did not receive regular nail care due to facility staff's failure to adhere to policy. The resident's nails were observed to be long and untrimmed, despite requests for assistance. CNAs were not allowed to trim the nails, and RNs were too busy, leading to unmet care needs.
Facility staff failed to maintain a resident's indwelling urinary catheter bag in a sanitary manner. The catheter bag was observed lying on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor. A nurse confirmed that catheter bags should be off the floor for infection control. The administrative staff were informed of the issue.
A resident with a wrist fracture received inadequate pain management due to unclear physician orders lacking specific parameters for administering Ibuprofen and Oxycodone. Pain medication was given even when the resident reported no pain. Interviews with facility staff revealed a lack of guidance on medication administration based on pain levels, and the facility's pain management policy was not followed.
The facility failed to receive timely pharmacy recommendations for two residents after medication regimen reviews. One resident's recommendations were delayed over a month due to a user error by the consulting pharmacist, while another resident's recommendations were delayed 12 days, contrary to the facility's 48-hour policy. The director of nursing confirmed the delays and the policy requirements.
Delayed Physician Notification After Resident Fall
Penalty
Summary
The facility staff failed to notify the physician in a timely manner of a resident's change in neurological status following a fall. The resident, who was on blood-thinning medications Eliquis and Aspirin, experienced a fall and was found on the floor with a large hematoma on the left forehead. Initial assessments indicated stable vital signs and neurological checks within normal limits, but the resident complained of head pain and exhibited altered consciousness. Subsequent assessments revealed unequal and non-reactive pupils, drowsiness, and nausea, yet there was a delay in notifying the physician. The clinical record review showed that the resident's pupils were sluggish in reacting to light shortly after the fall, but this was not immediately communicated to the physician. The facility's policy requires prompt notification of the physician for any change in a resident's neurological status, which was not adhered to in this case. Interviews with facility staff, including the director of clinical services and an LPN, confirmed that the nurse should have contacted the physician immediately upon observing sluggish pupils, as this is not considered normal. The facility's policies on neurological assessment and changes in a resident's condition emphasize the importance of timely communication with the physician when significant changes occur. However, the nurse responsible for the resident's care did not follow these protocols, resulting in a delay in addressing the resident's deteriorating condition. The executive director and other administrative staff were informed of these concerns during the survey, but no additional information was provided before the survey exit.
Failure to Include Anticoagulant Risks in Baseline Care Plan
Penalty
Summary
The facility staff failed to develop an accurate baseline care plan for a resident, identified as Resident #1, upon admission. The deficiency was noted in the omission of the risks associated with the resident's anticoagulant medications, Aspirin and Apixaban (Eliquis), from the baseline care plan. These medications, prescribed to the resident on admission, increase the potential for bleeding, a critical risk factor that should have been included in the care plan to ensure the resident's immediate health and safety needs were met. Interviews with facility staff, including a registered nurse and a licensed practical nurse, revealed a lack of comprehensive inclusion of necessary information in the baseline care plan. Both nurses acknowledged that the use of anticoagulants should have been documented in the care plan. The facility's policy mandates that a baseline care plan, which includes physician orders and other essential healthcare information, be developed within 48 hours of admission to address the resident's immediate needs. However, this requirement was not met for Resident #1, as the anticoagulant use was not documented, leading to the identified deficiency.
Delayed Response to Neurological Changes Post-Fall
Penalty
Summary
The facility staff failed to respond in a timely manner to a resident's change in neurological status following a fall. The resident, who was on blood-thinning medications Eliquis and Aspirin, experienced a fall and was found with a large hematoma on the left forehead. Initial assessments indicated stable vital signs and neurological checks within normal limits, but the resident complained of pain and exhibited altered consciousness. Subsequent assessments revealed unequal and non-reactive pupils, drowsiness, and inability to follow commands, yet there was a delay in contacting emergency services. Interviews with facility staff, including the director of clinical services and an LPN, highlighted that sluggish pupils should prompt immediate notification of a physician or nurse practitioner. The facility's policy on neurological assessments mandates notifying a physician of any changes in neurological status. However, there was no evidence that timely action was taken when the resident's pupils were noted to be sluggish immediately after the fall, leading to a delay in appropriate medical intervention.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility staff failed to protect a resident from abuse by another resident, resulting in harm, specifically a fractured wrist. The incident involved two residents, one of whom changed the TV channel without communicating with the other, leading to an altercation. The resident who was upset by the channel change stood and aggressively approached the other resident, who then pushed him. This push caused the resident to fall and fracture his wrist. The incident was unwitnessed, and both residents were separated immediately after the event. The resident who sustained the injury was sent to the emergency department for evaluation and returned with a diagnosis of a right wrist fracture. Both residents involved had low BIMS scores, indicating severe impairment in making daily decisions, and a history of traumatic brain injury, which can impair decision-making. The resident who pushed the other had no recollection of the incident. The facility's synopsis of the event and subsequent interviews with staff revealed that the staff responded by separating the residents and assessing the situation, but the incident was not witnessed by any staff members. The facility's comprehensive care plans for both residents were reviewed and updated following the incident. The care plans documented the residents' potential for aggression and behavioral issues. Interviews with staff indicated that they were aware of the procedures to follow in the event of resident-to-resident altercations, including separating the residents and notifying the appropriate personnel. However, the incident was classified as abuse, and the staff received education on abuse prevention and recognition after the event.
Deficiencies in Timely Documentation and Neurological Assessments
Penalty
Summary
The facility staff failed to adhere to professional standards of care for Resident #19 by not documenting progress notes in a timely manner. The clinical record review revealed that progress notes were written two to four days after the actual events occurred. Specifically, an LPN documented a fall four days late, an RN documented an assessment three days late, and the Director of Nursing documented an emergency room visit two days late. Interviews with the staff revealed that the delay was due to workload and lack of a specific policy on timely documentation. Additionally, the facility staff did not perform complete neurological assessments for Resident #19 following a fall. The Neurological Assessment Flow Sheet showed that pupil response was not documented in any of the 15 assessments conducted after the fall. Interviews with various staff members, including a nurse practitioner, RN, LPN, and the attending physician, confirmed that checking pupil response is a critical component of a thorough neurological assessment. The facility's policy on neurological assessments did not specify the necessary elements for a complete assessment. The lack of timely documentation and incomplete neurological assessments were brought to the attention of the facility's administration and regional director of operations. The facility's policies on charting and neurological assessments were reviewed, but they did not provide guidance on the timeliness of documentation or the elements of a thorough neurological assessment. No further information was provided before the survey exit.
Failure to Maintain Resident Dignity During Care Procedures
Penalty
Summary
The facility staff failed to maintain the dignity of Resident #74 during a dressing change procedure. An LPN, responsible for wound care, was observed writing on the dressing after it had been applied to the resident's buttock, contrary to the facility's policy which requires labeling to be done on a clean field. The LPN admitted to writing on the dressing while it was on the resident, acknowledging that it was not a comfortable practice for the resident. This incident was brought to the attention of the facility's administrative staff. Additionally, the facility staff did not ensure the dignity of Resident #72, who had an indwelling urinary Foley catheter. The catheter bag was observed without a privacy cover and was visible from the hallway, which is against the facility's policy that mandates the use of a drainage bag cover to maintain resident dignity. This oversight was also reported to the facility's administrative staff.
Failure to Maintain Resident's Call Bell Within Reach
Penalty
Summary
The facility staff failed to accommodate the needs of a resident by not maintaining the resident's call bell within reach. During an observation, the resident was found lying in bed without access to the call bell, which was on the floor beside the roommate's bed. The resident expressed the need for the call bell in case assistance was required. The call bell cord lacked a clip, preventing it from being attached to the bed sheets. An interview with a registered nurse revealed that staff are expected to clip call bells to bed sheets and ensure they are within reach during hourly or bi-hourly rounds. The facility's policy on answering call lights did not include instructions on maintaining call bells within residents' reach. The issue was brought to the attention of the administrator and the director of nursing, but no further information was provided before the survey exit.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility staff failed to provide written notification of a hospital transfer to the resident representative for one resident in the survey sample. On the date of the incident, the resident was found unarousable with labored breathing, indicating a change in condition. The licensed practical nurse contacted the physician, who recommended transferring the resident to the emergency department for evaluation. The responsible party was notified of the change in condition and the transfer via telephone, and the Assistant Director of Nursing was informed. However, there was no evidence of a written notice being provided to the resident representative. During the survey, the Director of Nursing was unable to provide evidence of a written notification to the resident representative, only documentation sent to the hospital. The facility's policy requires that a notice of transfer be provided to the resident and representative as soon as practicable, and to the LTC ombudsman when possible. Despite this policy, no written notice was documented or provided, leading to the deficiency noted in the survey findings.
Failure to Implement Comprehensive Care Plan for Urinary Catheter
Penalty
Summary
The facility staff failed to implement a comprehensive care plan for a resident with an indwelling urinary catheter. The care plan, dated 8/16/24, specified that a dignity bag or privacy cover should be used over the urinary collection bag when the resident is in social settings or when the bag is visible to others. On 9/9/24, the resident was observed lying in bed with the urinary catheter bag attached to the bed frame, without a privacy cover, and visible from the hall. This observation was confirmed during an interview with a registered nurse, who acknowledged that the care plan's purpose is to provide individualized care and that a privacy bag should be used to maintain dignity. The facility staff did not provide a policy regarding care plans when the issue was brought to the attention of the administrative staff.
Failure to Provide Adequate Nail Care for Diabetic Resident
Penalty
Summary
The facility staff failed to provide adequate ADL care to a dependent resident, specifically in maintaining trimmed fingernails. The resident, who is cognitively intact and requires substantial assistance for personal hygiene due to impairment in the upper extremities, reported that their fingernails were not being trimmed regularly. The resident, who has diabetes, stated that CNAs were not allowed to trim their nails, and RNs, who were responsible, were often too busy with medication administration to attend to nail care. Observations confirmed that the resident's fingernails were long and untrimmed, despite the resident's requests for assistance. The facility's policy on nail care specifies that diabetic residents should have their nails trimmed by licensed nurses to prevent infections and skin problems. However, the resident's nails remained untrimmed, indicating a failure to adhere to this policy. Interviews with staff revealed that CNAs were expected to report when nails needed trimming, but this process was not effectively implemented, leading to the resident's unmet care needs. The deficiency was acknowledged by the facility's administrative staff, including the administrator and the director of nursing.
Failure to Maintain Sanitary Conditions for Urinary Catheter
Penalty
Summary
The facility staff failed to provide proper care and services for an indwelling urinary catheter for one resident in the survey sample. The resident had a physician's order for an indwelling Foley catheter due to urinary retention. During an observation, the resident's catheter bag was found attached to the bed frame and lying on the floor, which is against the facility's policy for catheter care. This policy clearly states that catheter tubing and drainage bags should be kept off the floor to maintain sanitary conditions. An interview with a registered nurse confirmed that catheter bags should not be on the floor for infection control purposes. The administrative staff, including the administrator and the director of nursing, were informed of this concern.
Inadequate Pain Management Program for Resident
Penalty
Summary
The facility staff failed to maintain a complete pain management program for a resident who suffered a wrist fracture. The physician orders for pain management included Ibuprofen and Oxycodone, but the orders lacked specific parameters for when each medication should be administered based on the resident's pain level. This led to instances where pain medication was administered even when the resident reported a pain scale of zero, indicating no pain. Interviews with the facility's RN and the director of nursing revealed that there was no clear guidance on which medication to administer for specific pain levels. The RN acknowledged that the orders needed clarification from the physician, and the director of nursing admitted that the orders should have included parameters to guide medication administration. The director also noted the resident's history of drug abuse, which further complicated the pain management process. The facility's policy on pain assessment and management emphasized the importance of establishing a medication regimen with clear documentation and communication between the prescriber and staff. However, the lack of specific parameters in the physician orders and the administration of pain medication for a pain level of zero demonstrated a failure to adhere to this policy. The findings were communicated to the facility's administrator and director of nursing, but no further information was obtained before the survey exit.
Delayed Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to receive pharmacy recommendations after the completion of medication regimen reviews for two residents. For one resident, the pharmacy completed a medication regimen review on April 24, 2024, but the recommendations were not received by the facility until May 30, 2024. The consulting pharmacist admitted to a user error, stating that the recommendations were not attached to the initial email sent to the director of nursing. The facility's policy requires that the pharmacist's observations and recommendations be made available within 48 hours of the review, which was not adhered to in this case. For another resident, the facility staff did not obtain the pharmacy recommendations within 48 hours of the medication regimen review completed on August 30, 2024. The clinical record indicated that the review was completed, but the recommendations were not provided to the facility as required. The director of nursing confirmed that the recommendations had not been received and acknowledged the policy requirement for a 48-hour turnaround. As of the survey date, the recommendations had been delayed for 12 days, indicating a failure to comply with the facility's policy on timely communication of pharmacy recommendations.
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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 Goochland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakhurst Health & Rehabilitation | 15.7 mi | ★★★★★ | 5 | 0 |
| Our Lady Of Hope Health Center | 17.2 mi | ★★★★★ | 2 | 0 |
| Canterbury Rehabilitation And Healthcare Center | 18.3 mi | ★★★★★ | 20 | 2 |
| Shalom Gardens Health & Rehabilitation | 18.8 mi | ★★★★★ | 8 | 2 |
| Lakewood Manor | 18.8 mi | ★★★★★ | 0 | 0 |
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