Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Charlestown Community Inc during CMS and state inspections, most recent first.
Failure to Timely Report Allegations of Abuse and Neglect: The facility did not timely report an allegation of sexual abuse involving a resident with severe cognitive impairment or an allegation of neglect involving another resident with moderate cognitive impairment. An OT reported that a resident said someone touched them inappropriately, and the DON stated the allegation should have been reported the same day but was not. The facility also received a POA complaint of neglect related to inattentive care and hospitalization, but the report to the state survey agency was delayed.
A facility failed to thoroughly investigate an allegation of sexual abuse involving a resident with dementia and severe cognitive impairment. The resident reported unwanted touching, but the investigation did not include all staff with access to the room and only interviewed two cognitively intact residents; cognitively impaired residents were not assessed, and only nursing and dietary staff were interviewed.
Missing Food Service and Refrigerator Temperature Logs: The FSD and surveyor found multiple missing entries on the dish machine temperature log and pot sink sanitizer log, with required wash and rinse temperatures not recorded by dietary staff. The surveyor also found missing daily temperature entries for the 1st floor nourishment refrigerator and freezer, which the FSD said nursing staff were responsible for monitoring and documenting.
Facility staff did not obtain statements from all personnel present during the shifts when two separate abuse allegations occurred. In both cases, statements from assigned GNAs and an LPN were missing from the investigation files, and interviews were instead conducted with other staff not assigned to the relevant shifts. This resulted in incomplete investigations of the reported incidents.
Failure to Provide Written Transfer Notice: A resident was sent to the hospital, and the facility could provide the bed-hold notice to the resident's representative but could not produce the written notice stating the reason for transfer. The NHA said the facility had a form for this notice but could not explain why it was not used.
Inaccurate MDS coding was found for a resident with major depressive disorder who had active orders for Fluoxetine and gabapentin. The admission MDS did not code the depression diagnosis in Section I and did not code the anticonvulsant in Section N, and the quarterly MDS also omitted the depression diagnosis in Section I, although both the antidepressant and anticonvulsant were later coded in Section N. The RN MDS Coordinators and DON reviewed the assessments and acknowledged the inaccuracies.
A resident’s care plan was not revised after an MDS assessment showed a change of condition and hospice services were no longer indicated. An LPN documented that the resident had been discharged from hospice, but the active care plan still stated the resident was on hospice care. The DON confirmed the hospice care plan should have been removed.
Failure to Provide Hearing Aids: A resident who required bilateral hearing aids and assistance with application, removal, and storage was observed without the devices and asked for questions to be repeated. The resident said the hearing aids were not working, while a GNA was unaware of the need for them and an LPN later found two hearing aids in a charging case. The DON confirmed the GNA should have known about the hearing aids through report and the resource binder.
Failure to Follow Respiratory Care Procedures: Two residents had deficiencies in respiratory care. One resident had emergency O2 tanks in the room without O2 signage posted on the door, despite an order for PRN O2 for hypoxia. Another resident had O2 via NC and a nebulizer at bedside, but the O2 tubing and nebulizer tubing were not dated as required by the resident’s orders and the facility’s respiratory equipment policy.
A resident with a mood disorder due to a medical condition was recently discharged from hospice, and the physician documented treatment with Seroquel, Sertraline, and mental health follow-up. The CNS had stopped seeing the resident when hospice began and was not aware the resident was no longer on hospice, and the DON stated an order should have been written to communicate that the resident should have been seen by psychiatric services.
Psychotropic medications were not properly documented or monitored for three residents. One resident remained on Seroquel and Remeron for reported delusional thoughts, but the chart lacked behavior documentation to support the rationale. Another resident received PRN Xanax repeatedly without a documented PRN time frame and without sufficient behavior monitoring. A third resident’s Seroquel dose was increased for dementia with psychotic disturbance, but the record did not show monitoring for behaviors or EPS side effects.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving Resident #1 to the state survey agency. Resident #1 was admitted with diagnoses including Alzheimer's disease, dementia with psychotic disturbances, and delusional disorders, and had a BIMS score of 6, indicating severe cognitive impairment. During an OT evaluation, the resident stated that someone touched them inappropriately and gestured toward the private area. RN #10 documented that the resident reported someone was touching them and completed a skin assessment that found no visible injuries, redness, bruising, or signs of trauma. The DON stated the allegation should have been reported on the day the nurse was informed, but the facility did not report it until several days later. The facility also failed to timely report an allegation of neglect involving Resident #2. Resident #2 had diagnoses including senile degeneration of the brain, palliative care, type 2 diabetes mellitus, chronic kidney disease, and urinary tract infection, and had a BIMS score of 8, indicating moderate cognitive impairment. The resident's POA emailed the Director with concerns of neglect, and the Facility Reported Incident form indicated the Director was made aware of the allegation of inattentive care that led to hospitalization. The allegation was not reported to the state survey agency until the following day, and the Assistant Administrator stated his expectation was that allegations of neglect be reported in a timely manner.
Incomplete Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident with Alzheimer’s disease, dementia with psychotic disturbances, delusional disorders, and severe cognitive impairment. The resident reported to an Occupational Therapist that someone was touching him/her and gestured toward the private area. A head-to-toe skin assessment was completed and showed no visible injuries, redness, bruising, or signs of trauma, and the resident denied pain or discomfort. The facility investigation file did not show that all staff with access to the resident’s room were interviewed. Only two cognitively intact residents were interviewed, while cognitively impaired residents were not assessed. During interviews, the Assistant Administrator stated the facility interviewed two alert and oriented residents in the area, but did not assess cognitively impaired residents and acknowledged that this would have been a good idea. The Assistant Administrator later stated only nursing and dietary staff were interviewed, although housekeeping and therapy staff also had access to the resident and should have been interviewed.
Missing Food Service and Refrigerator Temperature Logs
Penalty
Summary
Sanitary and safe food service practices were not maintained in the kitchen and on the nursing unit nourishment refrigerator. During observation of the kitchen with the Food Services Director (FSD) present, the surveyor reviewed the dish machine temperature log for September 2025 and found missing wash temperatures for 9/12 PM, 9/13 PM, and 9/14 PM, as well as missing rinse temperatures for 9/2 PM, 9/12 PM, 9/13 midday, 9/13 PM, and 9/14 PM. The surveyor also reviewed the pot sink sanitizer log and found that the wash temperature for 9/2 PM was not recorded and that the wash and rinse temperatures for 9/4 PM were not recorded. When asked about the expectation for these logs, the FSD stated that wash and rinse temperatures were to be taken AM, midday, and PM and recorded by dietary staff. At the 1st floor nourishment refrigerator, the surveyor reviewed the posted refrigerator and freezer log and found missing temperature entries for 9/2, 9/3, 9/6, 9/7, 9/9, and 9/12 for both the refrigerator and freezer. The FSD stated that nursing staff were responsible for monitoring the nourishment refrigerators and freezers on the units and recording the temperatures daily on the log. The FSD also stated that the nourishment refrigerators and freezers on the nursing units were used to store food and beverages for residents brought in from outside by family and visitors.
Failure to Interview All Relevant Staff During Abuse Investigations
Penalty
Summary
Facility staff failed to conduct thorough investigations into two separate facility-reported incidents involving allegations of abuse. In both cases, the investigations did not include statements from all staff members who were present during the shifts when the alleged incidents occurred. Specifically, for one incident involving a resident, the staffing sheet indicated that four Geriatric Nursing Assistants (GNAs) and one nurse were present during the relevant shift, but their statements were not included in the investigation file. Instead, statements were collected from other staff not listed on the assignment sheet. The Assistant Nursing Home Administrator explained that statements are taken on a case-by-case basis, often relying on clinical rationale and summarizations rather than comprehensive staff interviews. In a second incident involving another resident, the investigation similarly lacked statements from the assigned LPN and a GNA who were present during the time of the alleged abuse. The surveyor confirmed with the facility administrator that a thorough investigation was not completed because not all staff who worked during the alleged incidents were interviewed. These omissions were identified during a recertification survey and were based on a review of facility records, staffing sheets, and staff interviews.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide the resident's representative with a written notice of the reason for transfer for Resident #92, who went to the hospital in mid June 2025. During record review on 9/18/25, the surveyor reviewed Resident #92's medical record and then requested the bed hold notice and reason-for-transfer notifications. On 9/19/25, the Nursing Home Administrator stated that the facility was able to provide the bed hold notice given to the resident's representative, but could not find the written notice with the reason for transfer. The NHA also stated that the facility had a form for this notice but could not explain why it was not used.
Inaccurate MDS Coding for Active Diagnoses and Medications
Penalty
Summary
The facility failed to complete an accurate MDS assessment for Resident #27. The resident was admitted with a diagnosis of major depressive disorder and had an active physician order for Fluoxetine 40 mg daily for depression as of 5/22/2025, as well as an active physician order for gabapentin 100 mg at bedtime for neuropathy pain as of 5/22/2025. Review of the admission MDS assessment dated [DATE] showed that major depressive disorder was not coded in Section I (Active Diagnoses). Section N (Medications) showed an antidepressant drug as taking and indication noted, but an anticonvulsant drug was not coded as taking and indication noted. Review of the quarterly MDS assessment dated [DATE] also showed that major depressive disorder was not coded in Section I (Active Diagnoses). Section N (Medications) on the quarterly MDS was coded as taking and indication noted for both an antidepressant drug and an anticonvulsant drug. During interview on 9/17/2025, the RN MDS Coordinators and the DON reviewed the admission and quarterly MDS assessments and acknowledged that the admission and quarterly assessments were inaccurate for Resident #27.
Care Plan Not Updated After Hospice Discharge
Penalty
Summary
The facility failed to review and revise Resident #51’s care plan after the resident’s condition changed and a new MDS assessment was completed. Resident #51 had an MDS assessment with an ARD of 7/28/25 that indicated a change of condition, and the special treatments section did not indicate hospice care. However, a nursing note written by an LPN on 7/22/25 stated that the resident was discharged from hospice services and would continue the plan of care. Despite this change, the resident’s active care plan still included that the resident was on hospice care. During interview, the DON reviewed the concern and confirmed that the hospice care plan should have been removed.
Failure to Provide Hearing Aids
Penalty
Summary
The facility failed to provide necessary adaptive equipment for Resident #86, who required hearing aids in both ears and needed assistance to apply, remove, and store them. On 9/15/25, the resident was observed in the common dining area without hearing aids and asked for questions to be repeated. Later that day, the resident stated that he/she had hearing aids but did not know why they did not work. A sign in the room instructed staff to remove the hearing aids each evening, place them in the charger, and ensure they were seated correctly. During interviews, the GNA assigned to the resident stated she normally did not work on the floor and had not seen any hearing aids for the resident. On 9/17/25, the LPN assigned to the resident stated the hearing aids would be placed after the resident got dressed in the morning, then retrieved a charging case from a table that contained two hearing aids that appeared to be charged. The DON reviewed the concern that the resident had been observed without hearing aids and that the GNA was not aware the resident required them, and confirmed the GNA should have known about the hearing aids through report and the resource binder.
Failure to Follow Respiratory Care Procedures
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents. For one resident, the surveyor observed two emergency oxygen tanks secured in carts in the room, but there was no oxygen signage posted on the room door at the time of the initial observation. The resident had a physician order for oxygen 2 liters per minute via nasal cannula as needed for hypoxia. An LPN later stated that oxygen signage should be posted when oxygen is in use, and the DON confirmed that oxygen signage was expected to be posted on resident room doors when oxygen tanks were in resident rooms. For another resident, the surveyor observed oxygen in use via nasal cannula and a respiratory nebulizer machine at the bedside. The oxygen tubing was not labeled with a date, although the humidifier bottle was dated, and the nebulizer tubing was also not labeled with a date. The resident had physician orders for oxygen via nasal cannula every shift for shortness of breath, DuoNeb solution for nebulization for wheezing, and weekly changing of oxygen tubing and humidification bottle. The facility policy required nebulizer tubing and oxygen tubing/nasal cannula tubing to be changed weekly, labeled with the date of change, and stored in a plastic bag when not in use. On a later observation, the oxygen tubing and nebulizer tubing remained unlabeled with a date, and the DON stated that the tubing was to be labeled, dated, changed weekly, and stored in a plastic bag when not in use.
Failure to Follow Behavioral Health Physician Instructions
Penalty
Summary
The facility failed to implement physician instructions for a resident’s behavioral health needs. Resident #51 had an MDS assessment with an ARD of 7/28/25 indicating a change of condition, and the special treatments section did not indicate hospice care. A physician note dated 8/6/25 stated the resident had recently been discharged from hospice and that the resident’s mood disorder due to a medical condition would be treated with Seroquel and Sertraline along with mental health follow-up. During interview, the Clinical Nurse Specialist stated she had stopped seeing the resident when the resident became a hospice resident and was not aware the resident was no longer receiving hospice services. The DON stated that an order should have been written to communicate that the resident should have been seen by psychiatric services.
Psychotropic Medications Lacked Documentation of Need and Monitoring
Penalty
Summary
The facility failed to appropriately prescribe and monitor psychotropic medications for three residents reviewed for unnecessary medications. The deficiency involved a resident receiving Seroquel and Remeron for distressing delusional thoughts and adjustment disorder, a resident receiving PRN Xanax for agitation and anxiety without a documented duration/time frame for use, and a resident receiving Seroquel for dementia with psychotic disturbance without documentation of monitoring for behaviors or extrapyramidal side effects. For one resident, the psychiatric provider documented that a gradual dose reduction was contraindicated because the resident continued to have distressing delusional thoughts and that quetiapine was at the lowest dose possible that had helped reduce distress. However, the resident’s MDS assessments for multiple assessment reference dates were marked “No” for hallucinations and “No” for delusions, and the surveyor could not find documented behaviors in the medical record to support the provider’s rationale. During interview, the psychiatric clinician stated that behaviors should be monitored and that she would review notes and speak with staff, but she confirmed she had not documented the behaviors described by staff when asked. For another resident, the record showed an order for alprazolam 0.25 mg PRN for agitation and anxiety, and the medication was administered on multiple days in August and September. The order did not include a duration or time frame for PRN use, and the surveyor noted insufficient documentation of ongoing monitoring of behaviors and symptoms related to the medication. For the third resident, Seroquel was increased from 12.5 mg to 25 mg and later to 37.5 mg at bedtime for dementia with psychotic disturbance and visual hallucinations, but the surveyor could not locate documentation showing that nurses monitored for extrapyramidal side effects or documented behaviors that would justify the dose increase. The DON later stated the resident had hallucinations but acknowledged there was no specific documentation to support that nature of behavior.
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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 Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Little Sisters Of The Poor | 0.1 mi | ★★★★★ | 5 | 0 |
| Ridgeway Rehab Center | 1.1 mi | ★★★★★ | 28 | 0 |
| Westgate Hills Rehab & Healthcare Ctr | 1.2 mi | ★★★★★ | 10 | 0 |
| Future Care Irvington | 1.4 mi | ★★★★★ | 23 | 0 |
| Frederick Villa Healthcare | 1.6 mi | ★★★★★ | 62 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.