Charlotte Hall Veterans Home
Charlotte Hall Veterans Home in CHARLOTTE HALL, MD — inspection on April 4, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on [DATE] at 9:10 AM, Social Worker Case Manager (SWCM)5 revealed she was
R17's guardian when R17 was sent to hospital.
During an interview on [DATE] at 10:46 AM, the Assistant Nursing Home Administrator (ANHA)25, she stated she remembered when G32 raised concerns, regarding failure to be contacted when staff sent R17 to hospital without notifying her. ANHA25 stated the staff on shift at that time was an agency nurse who did not follow facility policy.
During an interview on [DATE] at 12:38 PM, the Administrator said nurses or the social worker should contact the family when there was a change in condition.
215161 04/04/2025
Charlotte Hall Veterans Home 29449 Charlotte Hall Road Charlotte Hall, MD 20622
During an interview on 4/1/25 at 11:20 AM, the Director of Maintenance (DOM) stated that the facility had planned to have between 6-8 portable cooling units while the cooling tower was having scheduled maintenance.
They stated portable cooling units were placed in common areas in the impacted wings.
They stated they started taking temperatures in the hallways of impacted units on 4/30/24; temperatures were not taken in resident rooms but stated that resident rooms would have been hotter than the hallways.
They stated it was extremely hot the building and they set up fans to try to get more air flow and fans were placed in resident rooms.
They stated it was unpredictable for the weather to be as hot as it was during that time of year.
During an interview on 4/2/25 at 1:25 PM, the Safety and Security Director (SSD) stated the facility enacted a Code Purple on 4/30/24 at 4:00 PM.
They stated maintenance staff had started to monitor temperatures on 4/30/24 but were not keeping a log of the temperatures and were winging it.
They stated they created a form on 5/1/24 to track the temperatures for impacted areas and instructed maintenance and security staff to record temperatures every hour which started at 4:30 PM on 5/1/24.
They stated temperatures were monitored and recorded in the hallways on the impacted units, however, that resident rooms would have been even hotter.
They stated on 5/1/24 they went out to purchase fans.
They stated portable cooling units were placed in the hallways but that the electrical breakers could trip if too many cooling units were running at the same time.
They stated on the morning of 5/2/24 they were informed to start preparing rooms on a vacant unit.
The SSD stated they participated in a meeting following the Code Purple and they documented problems identified during the code.
They stated the facility had ample water and Gatorade to disperse to residents during the code, however, it was identified the need for additional need for thickened liquids/residents who required a different consistency was not taken into account and needed to be more readily available on the units.
They stated it was also identified that in planning for the cooling system outage, the vacant units should be prepared to be move-in ready in advance.
During an interview on 4/3/25 at 12:01 PM, the NHA stated that the cooling system maintenance was planned, and that maintenance had already been completed for cooling tower for the other wings.
They confirmed that the temperatures in the building were found to be above 81 degrees starting at approximately 12:00 PM on 4/30/24 and after 4 hours a Code Purple was enacted; the Code Purple was cleared at 12:00 PM on 5/2/24 and lasted approximately 48 hours.
They stated they did not recall whether anyone had reviewed or discussed the weather forecast prior to the cooling towers being taken out of service.
They stated notifications and actions to manage the heat and monitor residents were happening simultaneously.
They stated it was decided on the night of 5/1/24 that residents should be moved the following morning because the temperatures in the building were still consistently hot.
They stated vacant units were prepared to move residents; however, it was decided not to move residents since they were informed on the morning of 5/2/24 that the cooling towers would soon be functional.
They stated during review of the Code Purple, it was identified that vacant units should be move-in ready in event relocation is needed, that resident fluid intake should be documented and that there was an increased need for thickened liquids.
They stated with all staff dispersing fluids to promote hydration, it was difficult to determine how much fluid was provided to individual residents.
215161 04/04/2025
Charlotte Hall Veterans Home 29449 Charlotte Hall Road Charlotte Hall, MD 20622
not kept in storage in the kitchen. It was also identified that fluid intake should be documented in
Review of facility's Code Purple timeline and documentation revealed on 4/29/24 the cooling tower which serviced the A and B wings was taken out of service for scheduled maintenance and which impacted Resident #9's unit (3A). On 4/30/2024, outside temperatures rose and portable cooling units were unable to keep up with the demand to keep the building cool.
After temperatures above 81 degrees were recorded for more than four hours, a Code Purple was enacted at 4:00 PM on 4/30/24.
Upon request, the facility could not provide temperature monitoring/logs from 4/30/24 and prior to 4:30 PM on 5/1/24.
From 4:30 PM on 5/1/24 until 10:30 AM on 5/2/24, hourly temperatures were recorded during 18 opportunities on unit 3A; of the 18 recorded temperatures, 16 of the temperatures recorded to be above 81 degrees. On 5/1/24 temperatures in the evening hours on Unit 3A reached over 90 degrees.
215161
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 215161 B.
Wing 04/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Charlotte Hall Veterans Home 29449 Charlotte Hall Road Charlotte Hall, MD 20622
Review of facility's Code Purple timeline and documentation revealed the following:
On 4/29/24 the cooling tower which serviced the A and B wings was taken out of service for scheduled maintenance.
Since this was a planned outage, portable cooling units had been rented and placed on the impacted wings.
On 4/30/2024, outside temperatures rose and the portable units on the units were unable to keep up with the demand to keep the building cool.
After temperatures in the building were above 81 degrees for more than four hours in the building a Code Purple was enacted at 4:00 PM.
Maintenance and security staff were assigned to check/monitor temperatures for the impacted areas.
Upon request, the facility could not provide temperature monitoring logs from 4/30/24 and prior to 4:30 PM on 5/1/24.
Review of temperatures logs from 4:30 PM on 5/1/24 until 10:30 AM on 5/2/24, revealed hourly temperatures were recorded to be consistently above 81 degrees on the 2nd and 3rd floor care units on the A and B wings.
On 5/1/24 at 9:18 AM, the facility notified the County EMA of the Code Purple.
215161
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 215161 B.
Wing 04/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Charlotte Hall Veterans Home 29449 Charlotte Hall Road Charlotte Hall, MD 20622
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.