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Deficiency Records for Charlestown Community Inc

View the most recent health deficiencies and inspection results for Charlestown Community Inc. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Charlestown Community Inc. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2025-09-19 2026-01-06 N
Establish policies and procedures for volunteers. Fire Safety 2025-09-19 2026-01-06 N
Have proper medical gas storage and administration areas. Fire Safety 2025-09-19 2026-01-06 N
Ensure proper usage of power strips and extension cords. Fire Safety 2025-09-19 2026-01-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2025-09-19 2026-01-06 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2025-09-19 2026-01-06 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-09-19 2026-01-06 N
Install corridor and hallway doors that block smoke. Fire Safety 2025-09-19 2026-01-06 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2025-09-19 2026-01-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-09-19 2026-01-06 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2025-09-19 2026-01-06 N
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Health 2025-09-19 2025-11-05 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-09-19 2025-11-05 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2025-09-19 2025-11-05 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-09-19 2025-11-05 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2025-09-19 2025-11-05 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2025-09-19 2025-11-05 N
Ensure each resident receives an accurate assessment. Health 2025-09-19 2025-11-05 N
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-09-19 2025-11-05 N
Respond appropriately to all alleged violations. Health 2025-09-19 2025-11-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-07-14 2023-09-22 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-07-14 2023-09-22 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2023-07-14 2023-09-22 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2023-07-14 2023-09-22 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2023-07-14 2023-09-22 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-07-14 2023-09-22 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-07-14 2023-09-22 N
Provide and implement an infection prevention and control program. Health 2023-07-14 2023-09-22 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-07-14 2023-09-22 N
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Health 2023-07-14 2023-09-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-14 2023-09-22 Y
Respond appropriately to all alleged violations. Health 2023-07-14 2023-09-22 Y
Have proper medical gas storage and administration areas. Fire Safety 2023-07-14 2023-08-28 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-07-14 2023-08-28 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-07-14 2023-08-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-07-14 2023-08-28 N
Provide properly protected cooking facilities. Fire Safety 2023-07-14 2023-08-28 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-07-14 2022-09-26 Y
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-01-11 2019-04-10 N
Have exits that are accessible at all times. Fire Safety 2019-01-11 2019-04-10 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-01-11 2019-04-10 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-01-11 2019-04-10 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2019-01-11 2019-04-10 N
Have restrictions on the use of portable space heaters. Fire Safety 2019-01-11 2019-04-10 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2019-01-11 2019-04-10 N
Have proper medical gas storage and administration areas. Fire Safety 2019-01-11 2019-04-10 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-01-11 2019-04-10 N
Install an approved automatic sprinkler system. Fire Safety 2019-01-11 2019-04-10 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2019-01-11 2019-04-01 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2019-01-11 2019-04-01 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-01-11 2019-04-01 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-01-11 2019-04-01 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-01-11 2019-04-01 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-01-11 2019-04-01 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-01-11 2019-04-01 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2019-01-11 2019-04-01 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-01-11 2019-04-01 N
Ensure a qualified health professional conducts resident assessments. Health 2019-01-11 2019-04-01 N
Ensure each resident receives an accurate assessment. Health 2019-01-11 2019-04-01 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2019-01-11 2019-04-01 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2019-01-11 2019-04-01 N
Assess the resident when there is a significant change in condition Health 2019-01-11 2019-04-01 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2019-01-11 2019-04-01 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-01-11 2019-04-01 N
Respond appropriately to all alleged violations. Health 2019-01-11 2019-04-01 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-01-11 2019-04-01 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2019-01-11 2019-04-01 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-01-11 2019-04-01 N

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