Charlotte Hall Veterans Home

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure residents had their call bell within reach to notify the staff when assistance was needed, This deficient practice was evidenced in 5 (#80, #90, #125, #190, #191, #201) residents observed without their call bells during the initial observation rounds during the recertification survey.

Inspectors wroteBased on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensures safe and sanitary food service operations. This was identified during multiple observations of kitchen food service operations.

Inspectors wroteBased on observation and interview it was determined that the facility staff failed to ensure a dignified existence was maintained as evidenced of a resident's fitted sheet being heavily soiled and the mattress was half covered. This deficient practice was evidenced in 1 (#123) resident observed with a compromised dignified existence during the recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to attempt to decrease a resident's psychotropic medication when they had no documented behaviors for at least five months. This deficient practice was evidenced in 1(#80) of 1 resident records reviewed for gradual dose reductions of psychotropic medications during the recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to initiate a dental care plan for a resident who had dental concerns. This deficient practice was evidenced in 1 (#74) of 1 resident reviewed for dental concerns during the recertification survey.

Inspectors wroteBased on observations, record review, and interviews it was determined that the facility staff failed to provide a resident with a shower for several months and failed to consistently provide a resident with a shower. This deficient practice was evidenced in 2 (#4 & #80) resident records reviewed for ADL care during the recertification survey.

Inspectors wroteBased on observations and staff interview it was determined that the facility staff failed to: 1.) ensure proper temperature storage of medications to preserve medication integrity and 2.) properly label multi-dose medications with the complete date that the medication was opened. This was true for 2 of 7 medication carts reviewed during the annual survey.

Inspectors wroteBased on observation, infection control policy review, and interview with staff, it was determined that the facility: 1) failed to ensure that multi-use equipment was properly sanitized after each use and 2) failed to provide accurate transmission based precautions signage outside resident rooms. This was evident for 1 of 4 medication carts and 2 out of 5 residents' doors observed during the annual survey. It was also observed that the facility staff failed to maintain infection control practices for a resident who had a urinary drainage bag as evidenced by the drainage port being on the floor with the tubing being heavily soiled, and a resident's oxygen tubing was on the floor. This deficient practice was evidenced in 2 (#107, #209)) of 5 residents observed with a drainage bag or oxygen therapy during the recertification survey.

Inspectors wroteBased 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. This failure resulted in actual harm for Resident #9 that did not rise to the level of immediate jeopardy. Cross reference to F584: [...]

Inspectors wroteBased on record review and interviews during a complaint survey, the facility failed to ensure the resident environment was safe and comfortable for two of four occupied care wings. Specifically, the facility failed to maintain safe, comfortable temperatures on the A and B wings of the facility during planned maintenance of the cooling system; temperatures on these wings were consistently above 81 degrees Fahrenheit for approximately 48 hours. Cross reference to F684:

Inspectors wroteBased on observations, interviews, and record review, the facility failed to immediately notify the Resident court appointed Guardian (G32) when Resident (R17) experienced a significant change and deterioration of a life-threatening condition for one of 40 sampled residents. The facility census was 204. The Findings Include: Review of R17's Face Sheet documented R17 was admitted on [DATE]. The face sheet showed G32 was a medical court appointed guardian. Review of R17's care plan dated [DATE] directed staff to notify G32 of any changes to R17's health status. Record Review of the annual Minimum Data Set assessment (MDS), dated [DATE], revealed R17 had a BIMS score of 00/15 (indicating severe mental impairment). R17 was dependent on staff regarding activities of daily living (ADLs). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, resident record review, and staff and resident interviews, it was determined that the facility failed to: 1) ensure that residents were free from abuse (Resident #17); 2) ensure that residents were free from neglect (Resident #10); 3) maintain adequate supervision of residents with documented histories of aggressive behavior with care planned interventions in place including to perform routine checks to prevent potential 'inappropriate,' and 'aggressive' behavior (Resident #187); and 4) prevent abuse occuring from an employee towards a resident (Resident #235). This was found to be evident for 4 out of 49 residents reviewed for abuse and neglect. As a result of this failure, actual harm was identified for Resident #17.

Inspectors wroteBased on record review, interview, and review of pertinent facility documents and policies, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for * of * facility reported incidents reviewed.

Inspectors wroteBased on observation, medical record review and interviews with facility staff, it was determined that the facility failed to ensure that all employees providing direct care with residents were appropriately licensed and/or certified to care for the geriatric population. This was evident during the review of 2 of 2 employees providing 1:1 (one to one) care. A CNA (certified nursing assistant) is a person who has completed an approved nursing assistant program and has been certified as nursing assistant by the board of nursing. A GNA (geriatric nursing assistant) is a CNA who has passed the GNA state exam and is a skilled professional in providing activities of daily living (ADL i.e., bathing, dressing, toileting, feeding) care to the geriatric population.

Inspectors wroteBased on observation, interview, and medical record review, it was determined that the facility failed to identify the need to discontinue the use of plastic utensils and maintaining the dignity for a resident when s/he was no longer deemed unsafe. This was evident during the review of a facility reported incident.

Inspectors wroteBased on review of facility investigative material, it was determined that facility staff failed to change a resident when needed. This is evident for 1 (Resident # 222) out of 59 residents reviewed for facility reported incidents.

Inspectors wroteBased on interviews and record reviews it was determined the facility failed to ensure that residents were given a choice to have a shower. This was found to be evident for 2 out 2 Residents (#124 & #171) reviewed for bathing.

Inspectors wroteBased on observation, interviews, and record review it was determined that the facility failed to ensure a resident received appropriate respiratory care as evidenced by a resident oxygen tubing and humidifier bottle was outdated. This was found to be evident for 1 (Resident #135) out of 1 resident reviewed for respiratory.

Inspectors wroteBased on interview and review of pertinent facility documentation it was determined that the facility staff failed to obtain appropriate certification or licensure prior to working or practicing as a Geriatric Nursing Assistant (GNA), or to maintain enrollment in a Nurse Aide Training and Competency Evaluation Program (NATCEP). This was evident for 2 of 2 employees reviewed.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that during the readmission of a resident the facility staff failed to acquire the appropriate new medication orders and therefore ordered and administered medications from the resident's hospital admission. This was evident during the review of a facility reported incident and 1 of 3 readmissions. Resident (#83)

Inspectors wroteBased on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility.

Inspectors wroteBased on interviews and record reviews it was determined the facility failed to ensure that staff acknowledged a food allergy for a resident. This was found to be evident for 1 (Resident #147) out of 1 Resident reviewed for allergies.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to conduct routine surveillance and maintenance to assure that their pest control program was adequately maintained. This practice had the potential to affect all residents.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility staff failed to keep Resident #175 safe from injury by failing to intervene and ensure that Resident #175 was supervised when smoking and when Resident #175 showed a decline in cognitive status in activities of daily living. This was evident for 1 out of 7 residents reviewed for hospitalization and 1 out of 12 residents reviewed for accidents. It was determined that the facility's failure to ensure that Resident #175 was safe to smoke without supervision resulted in past non-compliance immediate jeopardy which existed from 7/5/18 through 10/20/18. The Nursing Home Administrator was notified on 11/30/18 at 4:30 P.M.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility staff failed to ensure that care plan interventions were implemented: 1) the facility failed to intervene and revise Resident #175's care plan related to tobacco use. This failure occurred when Resident #175 showed signs of decline in cognitive status and activities of daily living, indicating that the resident was not safe to smoke without supervision. It was determined that the facility's failure to revise Resident #175's care plan interventions resulted in an actual harm to the resident from a smoking related accident with injury, and 2) the facility failed to revise and update the care plan that addressed Resident #51's care after a change in condition. This was evident for 2 out of 12 residents reviewed during the survey process.

Inspectors wroteBased on observation, medical record review and resident and staff interviews it was determined the facility failed to ensure that a call light button was within reach for residents capable of using them. This was evident for 1 (Resident #165) out of 8 selected for review during the survey.

Inspectors wroteBased on observation and medical record review it was determined the facility staff failed to implement care plan interventions to ensure that residents' fall safety devices were operational. This was evident for 3 of 3 sampled residents (R#1, R#9 and R#10) reviewed for safety devices.

Inspectors wroteBased on medical records and staff interview, it was determined that the facility staff failed to establish a plan for Resident #328, related to the resident having a Foley catheter. This was evident for 1 out of 1 resident's investigated for a Foley catheter during the survey process.

Inspectors wroteBased on inspection of medication storage areas and staff interview it was determined the facility failed to ensure that the pharmacy assured accuracy in the labeling of a medication for Resident #159.

Inspectors wroteBased on review of medication storage areas and staff interview, it was determined the facility failed to ensure that medications that expire were labeled appropriately. This was evident for 2 medications found in 2 of the 15 storage areas reviewed during the survey.

Inspectors wroteBased on observation and staff interviews the facility staff failed to follow through on a physician's laboratory order for Resident #140. This was evident for 1 out of 5 residents investigated for unnecessary meds during the survey process.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to follow-up on a dental consult for Resident #18. This was evident for 1 of 1 residents reviewed during the survey.