The Veterans Home at Chelsea (VHC) did not always meet its veterans’ nursing care needs. Specifically, of the 35 veterans in our sample, 15 veterans required 1:1 care based on their assessment; and 4 of these 15 veterans were not assigned an extra staff member for 1:1 care.
In addition, nine veterans in our sample were labeled as fall risks in their assessments; however, we found that five of these nine veterans whose assessments deemed them as fall risks were not labeled as such on the daily assignment sheet. This may have resulted in staff members being unaware of the fall risk related to these veterans, increasing the risk of injury and the likelihood of providing substandard care to veterans.
Lastly, VHC was missing at least one assignment sheet for 24 veterans out of the 35 in our sample.
Failure to meet the needs of veterans, as determined by VHC’s own assessment of those needs, can lead to a variety of negative consequences for veterans, including an increased risk of mortality, physical decline, and infections, as well as emotional distress. It can also place excessive burdens on nursing staff members who are required to perform duties in excess of what was planned for during various shifts.
Authoritative Guidance
According to Section 51.130 of Title 38 of the Code of Federal Regulations (CFR),
The facility management must provide an organized nursing service with a sufficient number of qualified nursing personnel to meet the total nursing care needs, as determined by resident assessment and individualized comprehensive plans of care, of all patients within the facility 24 hours a day, 7 days a week.
Reasons for Issue
VHC does not have formal policies and procedures in place to ensure all veterans receive their required nursing care needs.
Recommendation
VHC should develop formal policies and procedures to ensure that all veterans’ nursing care needs are met based on their individualized plans of care and assessments.
Auditee’s Response
Since the establishment of [the Executive Office of Veterans Services (EOVS)] in March 2023, [Massachusetts Veteran Home (MVH)] Chelsea has undergone significant leadership, structural, and quality improvements. For the first time, the Home is led by experienced, licensed administrators, supported by a strengthened management team focused on professionalism, accountability, and compliance.
Under this leadership, MVH Chelsea achieved licensure by the Massachusetts Department of Public Health (DPH), certification by the Centers for Medicare & Medicaid Services (CMS), and continued recognition by the U.S. Department of Veterans Affairs (VA). These achievements confirm that the Home now meets regulatory and quality standards.
To support this transformation, EOVS engaged Health Management Associates (HMA), a nationally respected consulting firm, to assist both Veterans Homes in reviewing, standardizing, and modernizing clinical and nursing policies. The Homes now operate under a unified framework of approximately 165 policies, including 50 nursing-specific policies and digital protocols aligned with VA, CMS, and DPH requirements and best practices.
In addition, EOVS provides agency support, partnership and collaboration with both Veterans Homes through joint policy review, QAPI monitoring incident/accident reporting, grievance process management, Pinnacle report for customer satisfaction, and plan of correction support, as well as systemwide coordination efforts to ensure the consistent delivery of high-quality, veteran-centered care.
Auditor’s Reply
Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months as part of our post-audit review process.
| Date published: | January 14, 2026 |
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