Charlestown Community Inc
Inspection Findings
F-Tag F0605
F 0605 Level of Harm - Minimal harm or potential for actual harm
verify the nurses were monitoring the resident for extrapyramidal side effects of the medication or documenting when the resident had behaviors that would indicate the dose of the medication may need to be adjusted. Further review of the electronic medical record revealed the psychotropic medication was increased on 01/30/25 to Seroquel 37.5 mg PO every hour of sleep. There was no documentation to indicate why the medication was increased and if the staff was monitoring behaviors or side effects.
Residents Affected - Few
On 09/17/2025 at 2:03 PM during an interview with the Director of Nursing (DON) #2, he/she verbalized
they have a behavioral monitoring system where the Geriatric Nursing Assistants use a touch system where they document what they see. If there was any negative action or expression displayed the system would prompt them to answer more questions. The surveyor made DON #2 aware that if a nurse is assigned a resident who is prescribed psychotropic medication they are required to monitor the resident for behaviors and extrapyramidal side effect. The prescribing clinician should have that information available to determine if the medication is working or needs to be adjusted.
On 09/17/2025 at 3:37 PM the surveyor reported to Administrator #1 the nurses are not monitoring residents prescribed psychotropic medications for extrapyramidal side effects and not monitoring the resident for behaviors. Administrator #1 verbalized they have high risk rounds weekly which include residents who are prescribed psychotropic medications. They are going to work on having more precise documentation instead of generic documentation.
On 09/18/2025 at 11:05 AM DON #2 verbalized the resident goes to see a Neurologist at John Hopkins Hospital for Huntington's Disease and the Neurologist made the recommendation to increase the medication to Seroquel 37.5 mg R/T moderate Dementia with psychotic disturbance. The surveyor asked what warranted the increase of the medication. DON #2 verbalized the resident was having hallucinations;
they don't have documentation specific to that nature. Yes, they could have had documentation. They meet
on a weekly basis and talk about the residents who are prescribed psychotropic medications.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Charlestown Community Inc
719 Maiden Choice Lane Catonsville, MD 21228
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interviews it was determined that the facility staff failed to complete a thorough investigation of facility reported incidents as evidenced by not including statements from all staff who worked during the time the alleged incidents occurred. This deficient practice was evidenced in 2 (#36, #98) of 5 facility reported incident investigations reviewed during the recertification survey. The findings include:
On 09/16/2025 at 2:44 PM a review of the facility's investigation of the facility reported incident #325365 related to an allegation of abuse associated with Resident #36 revealed there were no statements from all staff who worked during the time of the alleged incident. On 09/16/25 at 11:15 AM during an interview with Assistant Nursing Home Administrator #3 the surveyor asked how did they determine who should be interviewed concerning the allegation? He/she verbalized after the alleged perpetrator was interviewed, the nursing supervisor, and the assigned nurse were interviewed. Also, statements were taken from people who worked on 03/10/25. The surveyor requested a copy of the staffing sheets for the date and shift when
the alleged incident occurred. At 12:00 PM a review of the staffing sheet for [NAME] Overlook 2 dated 03/10/25 3:00 pm - 11:00 pm revealed Geriatric Nursing Assistants #8, #9, #10, and #11 were included on
the staffing sheet but a statement from the GNA's were not included with the investigation. On 09/16/25 at 2:48 PM the surveyor reported to Assistant Nursing Home Administrator #3 there were not statements from all the staff who worked on 03/10/25 during the 3:00 pm - 11:00 pm shift when the alleged allegation of abuse was reported. Assistant Nursing Home Administrator #3 verbalized statements are taken on a case-by-case basis & they use a clinical rationale for everything. Often the staff may not have a statement, and they were more concerned about getting a summarization of interviews. The surveyor verbalized there were no statements from four GNA's and 1 nurse who worked in the neighborhood when the alleged incident occurred. There were interviews from seven other staff who were not included on the assignment sheet. On 09/18/25 at 10:31 AM a review of the facility's investigation related to the Facility Reported Incident (FRI) #325310 related to an allegation of abuse concerning Resident #98 revealed, a statement from all the staff who worked on [NAME] Overlook 2 on 07/13/23 during 7:00 am - 3:30 pm was not included in the investigation. There was not a statement from Licensed Practical Nurse (LPN) #30 who was assigned to the resident nor was there a statement from GNA #31 who worked when the alleged incident occurred. On 09/18/25 at 11:46 am the surveyor reported to Administrator #1 a thorough investigation was not completed because all the staff who worked during the alleged incident were not interviewed.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0628
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0641
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-09-19.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0657
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-09-19.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0676
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0676 during a standard health inspection conducted on 2025-09-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0695
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0740
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0740 during a standard health inspection conducted on 2025-09-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0812
Federal health inspectors cited Charlestown Community Inc in CATONSVILLE, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-09-19.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of Charlestown Community Inc.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
Charlestown Community Inc in CATONSVILLE, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CATONSVILLE, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Charlestown Community Inc or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.