Charlotte Hall Veterans Home

In the surveyor’s words

From the most serious findings on record at Charlotte Hall Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF761Aug 15, 2022

  Based on observations, staff interviews, and review of medical record documentation, it was determined that the facility failed to: 1) maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with confused and wandering residents. This practice was noted over three days (7/25/2022-7/27/2022) and included six instances where medication/treatment carts were observed unlocked and unattended. Unsecured carts were noted on 3 of the 6 nursing units. Additionally, the facility failed to: 2) ensure that a resident was assessed for being able to self administer medication. This was evident for 1 (Resident #78) of 1 resident reviewed for medication self administration. […]

• Actual harm, isolatedF684Apr 4, 2025

  Based on record review and interviews during a complaint survey, the facility failed to ensure each resident was provided care and treatment in accordance with professional standards of practice for one resident (Resident #9) of 40 sampled residents. Specifically, the facility failed to ensure Resident #9, a resident at risk for dehydration, was monitored for heat related illness and provided with sufficient hydration when temperatures in the building rose above 81 degrees from 4/30/24 until 5/2/24. On the morning of 5/2/24, Resident #9 was found nonresponsive with an elevated temperature and was sent to the hospital where they were treated for heat exhaustion and dehydration. Resident #9 experienced a significant change in condition following this event. […]

• Actual harm, isolatedF600Feb 17, 2023

  Based on staff interview, review of video footage, and review of facility documentation and medical record documentation, the facility failed to protect Resident #3 from neglect when Geriatric Nursing Assistant (GNA) staff were allowed to repeatedly place Resident #3 into restraint with no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation and continuation of restraint. During nine episodes of the noncompliant GNA-initiated restraints between 10/7/22 and 1/6/23 that lasted between approximately 2.5 and 7.5 hours each, staff failed to document increased monitoring of the resident for safety, failed follow orders regarding the use of a soft helmet, failed to allow the resident breaks to stretch, stand… […]

• Actual harm, isolatedF604Feb 17, 2023

  Based on staff interview, review of video footage, and review of facility documentation and medical record documentation, the facility failed to ensure staff did not impose unjustified restraints on one Resident (Resident #3). Geriatric Nursing Assistant (GNA) staff were allowed to repeatedly place Resident #3 into restraint with no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation and continuation of restraint. […]

• Actual harm, isolatedF686Feb 17, 2023

  Based on video footage review, record review, and staff interview, it was determined that the facility failed to provide the care needed to avoid the development of skin breakdown. This was evident for 1 (#3) of 3 residents reviewed for restraints. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 2/2/23 review of the medical record revealed that Resident #3 had a care plan initiated on 1/22/21 for the resident's risk for impaired skin integrity due to episodes of incontinence. The goal was that the resident would remain free of impaired skin integrity. […]