A list of the most recent deficiencies for Charlestown Community Inc. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-07-14 | 2023-09-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-14 | 2023-09-22 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-07-14 | 2023-09-22 | Y |
| 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 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-14 | 2023-09-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-09-22 | Y |
| 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 |
| 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 | Y |
| 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-14 | 2023-09-22 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-14 | 2023-09-22 | Y |
| 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 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-28 | 2023-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-08-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-28 | 2023-08-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-28 | 2023-08-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-28 | 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 |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-08-13 | 2021-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-09-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-13 | 2021-09-20 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-08-13 | 2021-09-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-13 | 2021-09-20 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-13 | 2021-09-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-03-07 | 2019-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-07 | 2019-04-10 | 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
| Assess the resident when there is a significant change in condition | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-11 | 2019-04-01 | N |
| Ensure a qualified health professional conducts resident assessments. | 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-01-11 | 2019-04-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-10-02 | 2017-11-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-10-02 | 2017-11-17 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-09-05 | 2017-10-20 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-05 | 2017-10-20 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-05 | 2017-10-20 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-09-05 | 2017-10-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-05 | 2017-10-20 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-05 | 2017-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-05 | 2017-10-20 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-05 | 2017-10-20 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-05 | 2017-10-20 | N |
