Inspection Reports for
Charlotte Hall Veterans Home
29449 Charlotte Hall Road, Charlotte Hall, MD, 20622
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 25, 2025
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The survey identified multiple deficiencies including failure to maintain residents' dignity, call bells not within reach, lack of gradual dose reduction for psychotropic medications, incomplete dental care plans, inconsistent shower provision, improper medication storage and labeling, unsafe food service practices, and inadequate infection prevention and control practices.
Deficiencies (8)
F 0550: The facility staff failed to ensure a resident's right to a dignified existence as evidenced by a heavily soiled fitted sheet and exposed mattress for Resident #123.
F 0558: The facility staff failed to ensure residents had their call bell within reach to notify staff when assistance was needed, observed in 5 residents.
F 0605: The facility staff failed to attempt gradual dose reduction of psychotropic medication for Resident #80 despite no documented behaviors for at least five months.
F 0656: The facility staff failed to initiate a dental care plan for Resident #74 who had dental concerns.
F 0677: The facility staff failed to provide showers consistently to Residents #4 and #80, with Resident #4 not having a shower for several months.
F 0761: The facility staff failed to ensure proper temperature storage of medications and proper labeling of multi-dose medications in 2 of 7 medication carts.
F 0812: The facility failed to maintain food service equipment and food storage in a safe and sanitary manner, including unlabeled raw chicken and improperly refrigerated foods.
F 0880: The facility failed to ensure proper sanitization of multi-use equipment and accurate transmission-based precaution signage, and failed to maintain infection control for residents with urinary drainage bags and oxygen therapy.
Report Facts
Residents affected: 5
Residents affected: 2
Medication carts reviewed: 7
Medication carts with deficiencies: 2
Residents reviewed for psychotropic medication: 1
Residents reviewed for dental concerns: 1
Residents reviewed for ADL care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Unit Manager #20 | LPN Unit Manager | Interviewed regarding resident dignity, call bell placement, and infection control findings |
| Psychiatric Nurse Practitioner #21 | Psychiatric Nurse Practitioner | Interviewed regarding gradual dose reduction for psychotropic medication |
| Director of Nursing | Director of Nursing | Interviewed regarding dental care plan and infection control |
| Geriatric Nursing Assistant #10 | Geriatric Nursing Assistant | Confirmed call bell placement findings |
| Geriatric Nursing Assistant #12 | Geriatric Nursing Assistant | Confirmed call bell placement and urinary drainage bag findings |
| Geriatric Nursing Assistant #17 | Geriatric Nursing Assistant | Interviewed regarding shower documentation process |
| Nurse #23 | Nurse | Observed medication storage and discarded improperly stored insulin pens |
| LPN #8 | Licensed Practical Nurse | Interviewed regarding multi-dose medication labeling |
| Registered Nurse #16 | Registered Nurse | Interviewed regarding call bell placement |
| Infection Preventionist #1 | Infection Preventionist | Interviewed regarding transmission-based precaution signage |
| Assistant Administrator #7 | Assistant Administrator | Reported on transmission-based precaution signage during exit conference |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding sanitization of multi-use equipment |
| LPN #14 | Licensed Practical Nurse | Observed during infection control findings related to oxygen therapy |
Inspection Report
Complaint Investigation
Census: 204
Deficiencies: 3
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to failure to notify a resident's guardian of a significant health change, unsafe environmental conditions due to high temperatures during cooling system maintenance, and inadequate care for a resident at risk for dehydration during a heat event.
Complaint Details
The complaint investigation substantiated failures in notification of a resident's guardian, environmental safety during a cooling system outage, and resident care related to hydration during a heat event. The facility was found to have failed in timely notification, maintaining safe temperatures, and providing adequate hydration and monitoring, resulting in harm to residents.
Findings
The facility failed to immediately notify a resident's court-appointed guardian of a significant health deterioration. The facility also failed to maintain safe and comfortable temperatures during a planned cooling system outage, resulting in prolonged high temperatures above 81 degrees Fahrenheit. Additionally, the facility failed to provide adequate hydration and monitoring for a resident at risk for dehydration during the heat event, resulting in actual harm.
Deficiencies (3)
F 0580: The facility failed to immediately notify Resident R17's court-appointed guardian of a significant change and deterioration in R17's life-threatening condition. Staff did not document attempts to contact the guardian before R17's death.
F 0584: The facility failed to maintain safe, comfortable temperatures on the A and B wings during planned cooling system maintenance, with temperatures consistently above 81 degrees Fahrenheit for approximately 48 hours, and failed to fully implement all Code Purple procedures.
F 0684: The facility failed to provide appropriate care and monitoring for Resident #9, who was at risk for dehydration, during the heat event. Resident #9 was found nonresponsive with a fever and hospitalized for heat exhaustion and dehydration, resulting in actual harm.
Report Facts
Facility census: 204
Duration of elevated temperatures: 48
Recorded temperatures above 81 degrees: 16
Fluid intake: 240
Fluid intake: 450
Resident temperature: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN15 | Licensed Practical Nurse | Interviewed regarding failure to notify Resident R17's guardian |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification failures and staff education during Code Purple |
| Social Worker Case Manager 5 | Social Worker Case Manager | Interviewed regarding expectations for guardian notification and resident family communication |
| Assistant Nursing Home Administrator 25 | Assistant Nursing Home Administrator (ANHA) | Interviewed regarding agency nurse failure to follow policy |
| Safety and Security Director | Safety and Security Director (SSD) | Interviewed regarding Code Purple response and environmental monitoring |
| Registered Nurse Unit Manager 10 | Registered Nurse Unit Manager (RNUM) | Interviewed regarding staff education and hydration monitoring during Code Purple |
| Director of Maintenance | Director of Maintenance (DOM) | Interviewed regarding cooling system maintenance and temperature monitoring |
| Medical Director | Medical Director | Interviewed regarding Resident #9's condition and care |
| Nurse Practitioner 24 | Nurse Practitioner | Interviewed regarding Resident #9's hospitalization and care during cooling outage |
Inspection Report
Routine
Deficiencies: 13
Date: Aug 15, 2022
Visit Reason
Routine inspection of Charlotte Hall Veterans Home to assess compliance with regulatory requirements including resident rights, care, safety, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate supervision and prevention of abuse, failure to provide scheduled showers, medication errors during readmission, unsecured medication carts, improper staff licensing and certification, food temperature and allergy management, and pest control issues.
Deficiencies (13)
F 0550: Facility failed to discontinue use of plastic utensils for a resident no longer deemed unsafe, impacting resident dignity.
F 0557: Facility staff failed to change a resident when needed, violating the resident's right to be treated with respect and dignity.
F 0561: Facility failed to ensure residents were given a choice to have showers, resulting in residents receiving bed baths instead of scheduled showers.
F 0600: Facility failed to maintain adequate supervision of residents with aggressive behavior and prevent abuse from an employee, resulting in actual harm to residents.
F 0610: Facility failed to thoroughly investigate allegations of abuse, omitting interviews of key staff and witnesses.
F 0695: Facility failed to ensure a resident received appropriate respiratory care as evidenced by outdated oxygen tubing and humidifier bottle.
F 0725: Facility failed to ensure all employees providing direct care were appropriately licensed or certified, allowing uncertified utility aides to provide hands-on care.
F 0728: Facility failed to ensure nurse aides were trained and competent, with two utility aides working as GNAs without certification.
F 0760: Facility failed to prevent significant medication errors during resident readmission by not obtaining appropriate new medication orders.
F 0761: Facility failed to maintain secure medication and treatment carts, leaving them unlocked and unattended multiple times, creating immediate jeopardy.
F 0804: Facility failed to ensure food was delivered at appropriate temperatures, with hot foods served below expected temperature standards.
F 0806: Facility failed to ensure staff acknowledged and accommodated a resident's food allergy, resulting in the resident being served shrimp despite a documented allergy.
F 0925: Facility failed to maintain an effective pest control program, with observed flies in resident rooms and a malfunctioning air curtain at a kitchen exit.
Report Facts
Residents reviewed for abuse: 59
Residents reviewed for bathing: 2
Residents reviewed for respiratory care: 1
Residents reviewed for medication self-administration: 1
Residents reviewed for allergies: 1
BIMS cognitive scores: 3
BIMS cognitive scores: 11
Medication carts unlocked observations: 6
Test tray temperature - oatmeal: 117
Test tray temperature - scrambled eggs: 108
Test tray temperature - bacon: 100
Test tray temperature - milk: 60
Test tray temperature - orange juice: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #71 | Utility Aide | Observed providing direct care without valid GNA certification; involved in resident abuse incident. |
| Staff #82 | Utility Aide | Worked as 1:1 caregiver without valid GNA certification. |
| GNA #83 | Involved in dignity violation related to resident changing. | |
| GNA #74 | Terminated for abuse of Resident #17 by bending resident's thumb. | |
| GNA #88 | Terminated for leaving resident unattended in whirlpool bath. | |
| LPN #46 | Unit Manager | Reported medication errors during resident readmission and lack of awareness of resident medication self-administration. |
| Charge Nurse #11 | Observed leaving medication cart unlocked. | |
| LPN #9 | Observed leaving medication cart unlocked. | |
| Unit Manager #7 | Observed unlocked treatment cart and reported wandering residents. | |
| Food Service Compliance Officer #27 | Interviewed regarding food temperature and allergy management. | |
| Nurse Educator #35 | Involved in allergy incident response and staff education. | |
| Staff Development Coordinator #35 | Provided information on staff certification and training. | |
| Staffing Coordinator #75 | Interviewed about staff assignments and awareness of utility aides' scope. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 4, 2018
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure call light accessibility, incomplete care plans, inadequate supervision of a resident who smokes, inaccurate medication labeling, failure to follow up on laboratory and dental orders, and lack of urology follow-up for a resident with a Foley catheter.
Deficiencies (9)
F 0558: The facility failed to ensure that a call light button was within reach for residents capable of using them, as observed for Resident #165.
F 0656: The facility failed to implement care plan interventions to ensure that residents' fall safety devices, such as wheelchair cushion alarms, were operational for 3 residents.
F 0657: The facility failed to revise care plans for residents, resulting in actual harm to Resident #175 from a smoking-related injury and failure to update Resident #51's fall care plan after falls.
F 0689: The facility failed to provide adequate supervision to prevent accidents, resulting in immediate jeopardy due to Resident #175 smoking unsupervised and sustaining burns.
F 0690: The facility failed to establish a plan for Resident #328 related to Foley catheter care and lacked urology follow-up.
F 0755: The facility failed to ensure pharmacy accuracy in medication labeling, as a Flovent discus was labeled with an incorrect expiration date.
F 0761: The facility failed to ensure medications that expire were labeled appropriately, including an undated influenza vaccine vial and a Flovent discus with incorrect expiration labeling.
F 0770: The facility failed to follow through on a physician's laboratory order for Resident #140, missing scheduled bloodwork for Hemoglobin A1c.
F 0791: The facility failed to follow up on a dental consult for Resident #18, resulting in no dental appointment being scheduled prior to surveyor intervention.
Report Facts
Residents reviewed for fall safety devices: 3
Residents reviewed for hospitalization: 7
Residents reviewed for accidents: 12
Residents reviewed for Foley catheter: 1
Medication storage areas reviewed: 15
Residents reviewed for unnecessary medications: 5
Residents reviewed for dental services: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geriatric Nursing Assistant (GNA) staff #11 | Observed repositioning call light for Resident #165 and involved in smoking screen | |
| Staff member #8 | Verified call light placement for Resident #165 | |
| Staff member #7 (Unit Manager) | Interviewed about call light policy | |
| Director of Nursing | Interviewed regarding smoking safety and care plan implementation | |
| Certified Dementia Practitioner, Staff #11 | Completed smoking screens and interviewed about Resident #175 | |
| Unit Manager #2 | Interviewed about dental appointment scheduling and medication labeling | |
| Pharmacist #4 | Interviewed about medication labeling practices | |
| Staff nurse #3 | Confirmed undated influenza vaccine vial |
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