Charlestown Community Inc

In the surveyor’s words

From the most serious findings on record at Charlestown Community Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 14, 2023

  44440 Based on observation, staff interviews, medical records review, review of facility reports, and facility's policy and procedures it was determined that the facility failed to: 1) ensure appropriate processes were followed and adequate supervision was in place to prevent a cognitively impaired resident with exit seeking behaviors and a history of a previous elopement from leaving the building. This was evident for 1 Resident (#55) out of 3 Residents reviewed for actual elopements reviewed during an annual and complaint survey. 2) ensure fall prevention interventions were in place for a resident with a history of falls. This was found evident of 1 (#49) of 7 residents reviewed for falls during an annual and complaint survey. The Findings Include: 1. […]

• No harm, potential for more than minimal, patternF812Sep 19, 2025

  Based on observation, staff interviews and surveyor record review it was determined that the facility failed to ensure sanitary and safe food service practices. This was found to be evident in 1 out of 2 nourishment refrigerators on the nursing units and in the kitchen. The findings include:On the initial tour of the kitchen at 8:35 AM on 9/15/2025 with the Food Services Director (FSD) in attendance, the surveyor reviewed the dish machine temperature log for the month of September 2025. The surveyor observed that the dish machine temperature log did not have wash temperatures recorded for 9/12 PM, 9/13 PM, and 9/14 PM, and did not have rinse temperatures recorded for 9/2 PM, 9/12 PM, 9/13 midday, 9/13 PM, and 9/14 PM. […]

• No harm, potential for more than minimal, patternF610Jul 14, 2023

  Based on record review and staff interview, it was determined that the facility staff failed to ensure that a facility reported investigation had been completed. This was evident for 1 of 18 facility reported incidents reviewed during the recertification survey. The findings include: If abuse or certain other incidents occur at a Maryland nursing home, the nursing home is required to report the incident to the state. These reports are called facility reported incidents. On 09/12/2022 facility staff reported in a facility reported incident, that gabapentin (an anticonvulsant that treats seizures and pain) capsules for Residents #47, #55, and #209, could not be accounted for. On 07/11/2023 at 1:30 PM the completed investigation for the missing capsules was requested by surveyor. […]

• No harm, potential for more than minimal, patternF638Jul 14, 2023

  Based on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 2 of 2 residents (#117 and #1) reviewed. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF684Jul 14, 2023

  Based on observations, interviews and record reviews, it was determined the facility failed to: 1) identify and provide treatment according to the resident's comprehensive care plan and professional standard for constipation (Resident # 60), 2) maintain correct narcotic count (Resident # 44), and 3) failed to ensure resident's skin was completely assessed and documented per physician orders (Resident # 199). This was found for 3 (# 60, # 44, and #199) out of 66 residents reviewed during the recertification survey. The findings include: 1) On 7/05/23 at 11:26 AM, the surveyor reviewed Resident #60's medical records. […]