Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Charlotte Hall Veterans Home during CMS and state inspections, most recent first.
Facility staff failed to ensure call bells were within reach for multiple residents. During observation rounds, several residents were found with call bells behind the bed, hanging too low, or placed on the opposite side of the bed or near the foot of the bed, and GNA staff confirmed some of the findings. An RN stated the call bell should always be within reach and staff should check for it each time they enter a resident’s room.
Food service equipment and storage areas were observed in an unsanitary condition, including eyeglasses and a personal drinking container on top of the dishwasher and empty soap and paper towel dispensers at hand-wash sinks. Raw chicken in the walk-in refrigerator lacked a thaw date label, and Refrigerator #4 was found at 50 to 48 degrees Fahrenheit while holding egg salad and multiple deli meat sandwiches; the CDM measured the egg salad at 56 degrees Fahrenheit.
Dignified Existence Not Maintained: An LPN was observed in a resident’s room while the resident’s fitted sheet was heavily soiled and the mattress was only half covered. The LPN walked past the resident and left without offering assistance, and there was no EHR documentation that help had been offered and refused. An LPN unit manager stated the resident is independent and resistant to care, but acknowledged staff should still offer assistance.
A resident remained on Quetiapine 25 mg without another GDR attempt even though behavior monitoring showed no behavioral problems for months. Psychiatric notes referenced a prior failed GDR with agitation, cursing, and inability to follow safety precautions, while later notes said a GDR was not indicated. The psych NP stated another GDR had not been attempted since the prior one and that the goal was to use the lowest dose possible.
A resident had documented dental concerns and an appointment request for dental pain, but the EHR showed no dental care plan was in place. The resident’s RP reported ongoing problems with the bottom teeth and that the resident was supposed to return to the dentist. The DON acknowledged the missing care plan and stated that Unit Managers and nurses are responsible for completing care plans, with MDS support.
Failure to Provide Scheduled Bathing Assistance: Staff failed to consistently provide bathing assistance to two residents who needed ADL care. One resident reported not having a shower in months, and the EHR showed no bathing documentation for an extended period. Another resident was scheduled for showers twice weekly, but the record lacked documentation for multiple scheduled showers and did not show any refusals.
Improper storage and labeling of medications were found in 2 of 7 med carts reviewed. Surveyors observed unopened insulin pens kept in a med cart even though they were labeled to refrigerate until opened, and they also found a multi-dose solution bottle with an illegible open date. An LPN stated she could not read the date and did not know the correct procedure when the open-date label was missing.
The facility failed to properly disinfect multi-use equipment after use and posted inaccurate transmission-based precaution signage outside a room shared by two residents. Surveyors also observed a resident with a urinary drainage bag whose drainage port was on the floor and tubing was heavily soiled, and another resident’s oxygen tubing was on the floor while still attached to the concentrator. An LPN, GNA, DON, and AA confirmed the findings.
A resident with advanced neurological and swallowing disorders, dependent on staff for care and at risk for dehydration, was not adequately monitored or provided with sufficient hydration during a period of high indoor temperatures following a cooling system outage. Despite protocols for heat emergencies, staff failed to document fluid intake or monitor the resident's condition, leading to the resident being found nonresponsive and requiring hospital treatment for heat exhaustion and dehydration.
During a planned maintenance outage of the cooling system, the facility failed to maintain safe and comfortable temperatures on two care wings, with temperatures exceeding 81°F for approximately 48 hours and reaching over 90°F in some areas. Portable cooling units and fans were insufficient, temperature monitoring was inconsistently documented, and the County EMA was not notified promptly. Staff monitored for heat-related illness and provided hydration, but lacked specific assignments and consistent documentation, and did not ensure all fluid consistencies were available for residents with special needs.
A resident with severe mental impairment and a court-appointed medical guardian experienced a significant change in condition and was sent to the hospital without immediate notification to the guardian, as required by the care plan. Staff interviews confirmed the expectation to notify the guardian, but documentation and communication were lacking due to an agency nurse not following policy.
Call Bells Not Within Reach of Residents
Penalty
Summary
Facility staff failed to ensure residents had their call bells within reach to notify staff when assistance was needed. During initial observation rounds, five residents were found without their call bells in reach: one resident had the call bell behind the bed, another had it hanging off the left side of the bed close to the floor, another had it hanging on the right side of the bed, one resident sitting in a wheelchair had the call bell on the wall on the opposite side of the bed, and another resident up in a chair near the window had the call bell on the wall near the foot of the bed. GNA staff confirmed several of these observations. During interview, an RN stated the call bell should always be within reach of the resident and staff should let the resident know where it is located, and that each time they go into a resident's room they should check to make sure the resident has the call bell.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food service equipment and storage areas were not maintained in a sanitary manner during multiple kitchen observations. During a kitchen tour, a pair of eyeglasses and a 30-ounce personal drinking container were observed on top of the dishwasher, and the hand-wash sinks in the dishwashing area and near the walk-in refrigerator had empty soap and paper towel dispensers. In the walk-in refrigerator, a long silver tray contained three large blue bags of raw chicken without a label noting the thaw date. Refrigerator #4 was observed at 50 degrees Fahrenheit and then 48 degrees Fahrenheit ten minutes later, and it contained a tray of egg salad dated 7/15/25 and several snack trays, including dozens of deli meat sandwiches. The Certified Dietary Manager checked the egg salad with a thermometer and found it at 56 degrees Fahrenheit, after which the deli meat sandwiches and egg salad were discarded.
Dignified Existence Not Maintained
Penalty
Summary
Facility staff failed to ensure Resident #123 maintained a dignified existence when the resident’s fitted sheet was observed to be heavily soiled with large spots of a green substance and only half of the mattress was covered. During the observation, an LPN was in the room giving medications to the resident’s roommate, then walked past Resident #123 and left the room without offering assistance. The surveyor reviewed the electronic health record and found no documentation showing that assistance had been offered and refused. During an interview, the LPN Unit Manager stated the resident tries to be as independent as possible and is resistant to care, that this should be care planned, and that staff allow the resident to meet his needs on his own; when asked whether staff should at least offer assistance to a resident who is sometimes resistant to care, the LPN Unit Manager said yes.
Failure to Attempt GDR of Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of a resident’s psychotropic medication despite documentation showing no behavioral problems for at least five months. Record review for Resident #80 showed psychiatric notes from 12/19/24, 03/20/25, and 06/19/25, including a prior failed GDR attempt in 11/24 when the resident reportedly became agitated, used profane language, and could not follow safety precautions after the medication was decreased. However, behavioral monitoring documentation from 03/01/25 through 07/21/25 showed no observed behavioral problems before or after administration of Quetiapine 25 mg, and the later psychiatric notes stated that a GDR was not indicated. During interview, the Psychiatric NP stated the last GDR was done in November, that another GDR had not been attempted since then, and that the resident had been stable enough that a GDR could be attempted if stable for a while.
Failure to Initiate Dental Care Plan
Penalty
Summary
Facility staff failed to initiate a dental care plan for Resident #74 despite documented dental concerns. On 07/17/2025, the resident’s responsible party/emergency contact told the surveyor that the resident had a lot of issues with the bottom teeth and was supposed to be taken back to the dentist. On 07/21/2025, review of the resident’s EHR showed there was no dental care plan in place even though the facility was aware of the dental concerns. The surveyor also obtained an appointment request dated 07/07/2025 related to dental pain. During an interview on 07/21/2025, the DON acknowledged that the resident did not have a dental care plan and stated that Unit Managers should ensure care plans are completed, while MDS helps but the nurses are ultimately responsible for completing the care plans.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
Facility staff failed to provide bathing assistance for two residents who were unable to complete ADLs independently. During observation rounds, one resident stated he/she had not had a shower in several months, and the surveyor noted a strong odor of urine in the resident’s room. Later, the resident stated staff told him/her they did not have a wheelchair to take him/her to get a shower. The resident’s bath schedule showed showers were planned for Wednesday and Saturday, but the electronic health record contained no documentation of a shower from 04/01/25 through 07/22/25. For another resident, the shower schedule on 2B showed showers were planned for Monday and Thursday, but the facility’s documentation did not verify showers on 07/17, 07/03, 06/26, 06/12, 06/05, or 06/02. There was no documentation that the resident refused a shower. During interview, a GNA stated residents choose their preferred ADL care and staff document it in the computer, including refusals, and that the nurse is made aware if a resident consistently refuses. The record review and interviews showed the resident did not consistently receive the scheduled bathing care.
Improper Storage and Labeling of Medications
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in 2 of 7 medication carts reviewed. During a medication storage observation on the first floor, surveyors found 2 unopened insulin pens in the High Hall medication cart even though they were marked to refrigerate until opened; Nurse #23 confirmed the pens should have been refrigerated until opened and discarded them. In a separate observation, surveyors found a multi-dose solution bottle in a medication cart with an illegible handwritten open date, and an LPN stated she could not read the date because it had worn away and was not aware of the correct procedure when the open-date label was missing.
Infection Control Lapses With Equipment Cleaning, Precaution Signage, and Resident Tubing
Penalty
Summary
The facility failed to ensure that multi-use equipment was properly sanitized after each use and failed to provide accurate transmission-based precaution signage outside resident rooms. During the annual survey, a surveyor observed that a Freestyle Libre 2 was being cleaned with 70% isopropyl alcohol wipes after each use, while the facility policy reviewed on 7/23/25 stated that multi-use equipment must be disinfected with EPA-approved germicidal/virucidal disinfectant wipes before and after each patient use. The Administrator and DON later acknowledged the concern and confirmed that multi-use equipment should be cleaned with disinfecting wipes after each use and that the highest level of transmission-based precaution signage should be displayed in residents’ rooms. The survey also identified infection control concerns with two residents. Resident #209 was observed with a urinary drainage bag emptying port on the floor and tubing that was heavily soiled; the tubing was dated 06/25/25, and the GNA confirmed the findings. Resident #107 was observed with oxygen therapy in use, but the resident was not in the room, and the nasal cannula tubing was on the floor while still attached to the oxygen concentrator; the humidification water container was labeled 07/07/25. In Room B112, both contact precaution and enhanced barrier precaution signs remained posted outside the room, and the AA later stated that one resident in the room was on contact precautions while the other was on enhanced barrier precautions, which meant an individual entering the room would not know which precautions applied to which resident.
Failure to Monitor and Hydrate Resident During Heat Event Resulting in Harm
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice for a resident at risk for dehydration during a period of elevated indoor temperatures. When the cooling system servicing the resident's unit was taken out of service for maintenance, indoor temperatures rose above 81 degrees for an extended period, with some readings exceeding 90 degrees. Despite the facility enacting a 'Code Purple' for severe hot weather, there was a lack of consistent temperature monitoring and documentation, and the facility could not provide temperature logs for a significant portion of the affected period. The resident involved had diagnoses including Parkinson's Disease, dementia, and dysphagia, and was assessed as being dependent on staff for most activities of daily living. The care plan identified the resident as being at risk for dehydration, with interventions to observe for signs and symptoms of dehydration and to encourage thickened fluid intake. However, during the period of elevated temperatures, the resident's fluid intake was inadequately documented, with only minimal amounts recorded and no fluids documented on the day the resident was found nonresponsive. There were also no nursing progress notes entered during the critical period, and staff interviews confirmed that routine charting of hydration was not completed during the Code Purple. On the morning following the period of high temperatures, the resident was found nonresponsive with an elevated temperature and was sent to the hospital, where they were treated for heat exhaustion and dehydration. Medical staff confirmed that the resident was at increased risk for dehydration due to their medical conditions and thickened liquid requirement, and that the lack of hydration and monitoring contributed to the resident's significant change in condition. The facility's failure to ensure sufficient hydration and monitoring during the heat event resulted in actual harm to the resident.
Failure to Maintain Safe and Comfortable Temperatures During Planned Cooling System Outage
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents on two of its care wings during a planned maintenance outage of the cooling system. The cooling tower servicing the A and B wings was taken offline for scheduled maintenance, and although portable cooling units were rented and placed in the affected areas, they were insufficient to keep temperatures below 81 degrees Fahrenheit. Temperatures in the building exceeded 81 degrees for more than four hours, triggering a Code Purple, and remained consistently above this threshold for approximately 48 hours, with some areas reaching over 90 degrees. Temperature monitoring was not consistently documented, as logs were unavailable for the initial period of the outage, and temperature checks were only conducted in hallways, not in resident rooms, which were reported to be even hotter. The facility's emergency procedure for severe hot weather, Code Purple, required specific actions such as moving residents to cooler areas, monitoring for heat-related illnesses, and notifying emergency management agencies. However, the County Emergency Management Agency (EMA) was not notified until the day after the Code Purple was enacted, despite the event being a planned outage. Staff were educated to monitor residents for signs of heat exhaustion and dehydration and to provide additional hydration, but there were no specific assignments for monitoring hydration, and fluid intake documentation was inconsistent. The facility also did not ensure that different consistencies of fluids were readily available for residents with special needs during the event. Interviews with facility staff and management revealed that the response to the heat event was reactive rather than proactive. The Director of Maintenance and Safety and Security Director acknowledged that temperature monitoring was not systematically logged at first and that the portable cooling units and fans were not sufficient to maintain comfortable conditions. The decision to move residents to a vacant, cooler unit was delayed and ultimately not carried out because the cooling system was restored. The facility identified several shortcomings in their response, including the need for better preparation of vacant units for potential relocation and improved documentation and provision of fluids, but these were only recognized after the event.
Failure to Notify Guardian of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's court-appointed medical guardian when the resident experienced a significant change in condition and subsequent deterioration of a life-threatening condition. The resident, who had severe mental impairment and was dependent on staff for activities of daily living, was sent to the hospital for evaluation after being found with elevated respiration and unresponsiveness. Documentation showed that the medical provider was notified and orders were given to send the resident to the hospital, but there was no evidence that the guardian was contacted at the time of the transfer, as required by the resident's care plan. Interviews with facility staff, including an LPN, the DON, a social worker, and the assistant administrator, confirmed that the expectation was to notify the resident's representative or guardian immediately in the event of a significant change in condition. The guardian expressed disappointment at not being informed when the resident was sent to the hospital. The lack of documentation and failure to notify the guardian was attributed to an agency nurse not following facility policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlotte Hall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Acres Nursing And Rehab | 10.4 mi | ★★★★★ | 17 | 0 |
| Calvert County Nursing Ctr. | 11.3 mi | ★★★★★ | 29 | 0 |
| Waldorf Center | 11.9 mi | ★★★★★ | 27 | 0 |
| Complete Care At Laplata Llc | 12.1 mi | ★★★★★ | 12 | 0 |
| Restore Health Rehabilitation Center | 12.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Charlotte Hall Veterans Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.