Senior officials under former Gov. Larry Hogan acknowledged deficiencies at Charlotte Hall Veterans Home were widely-known, while the two-term Republican’s veterans affairs secretary said he’ll take the heat for the worsening conditions.
The state-owned, privately-run assisted living and skilled nursing facility’s quality rating hit rock bottom in January — declining from a four-star rating in 2019 to one star — the month Hogan’s administration left office, after state inspection reports revealed abuse and neglect of the honorably discharged veterans who are its residents.
In a series of reports available online, state inspectors detailed the facility’s failures to keep patients safe from each other and from staff. Also documented was the staff’s failure to execute care plans and failure to keep patients’ conditions from worsening.
Despite reports of abuse and neglect dating back to 2018, the Maryland Department of Veterans Affairs requested that the state spending board renew its contract with private contractor HMR of Maryland LLC as recently as 2021.
“I’ll take the blame. I was the secretary,” George W. Owings III said. Owings served under three governors as secretary for the Department of Veterans Affairs, the agency responsible for the state’s only veterans home.
Owings said he was first made aware that conditions at Charlotte Hall were declining in “late 2021, early 2022.″ He faulted the pandemic and nursing shortages for straining HMR’s staffing resources.
“If you can’t step up and take the blame, then get out of the job,” Owings said.
His agency had a good working relationship with HMR of Maryland LLC, he said. Charlotte Hall is one of 12 veterans homes in four states overseen by South Carolina-based HMR Veterans Services. Owings said he was caught “off guard when the new governor just shut things down all together.”
Owings said he never discussed conditions at Charlotte Hall Veterans Home with his former boss, Hogan, nor did Hogan ask him about the home.
“I have never, ever — make a quote on this — been one-on-one with the governor about Charlotte Hall, ever,” Owings said.
Hogan spokesperson David Weinman said in a statement that it would have been “grossly irresponsible” to remove needed health care workers amid a pandemic and a nursing shortage without an alternative to ensure continuity of service.
“That’s why the Board of Public Works had no reasonable choice but to renew the contract,” he said.
One member of the three-member board responsible for approving state contracts said she was unaware of any inspection reports outlining abuse or neglect of the home’s residents.
Gov. Wes Moore called the conditions at Charlotte Hall a “moral failure of government,” and admonished the Hogan administration for not briefing the Moore team on the poor conditions. Last week Moore, a Democrat, announced he had taken steps to end the state’s 21-year relationship with the company contracted to run the 454-bed facility.
In response, Weinman said, “Governor Hogan is proud that his administration ran the most open, transparent, and accessible transition process in Maryland history. In addition to preparing transition documents with high-level operational information about each agency, the Hogan administration provided the incoming Moore administration three senior-ranking contacts at every state agency and directed them to facilitate any briefings or make available any information that they requested.”
Weinman did not work in Hogan’s administration but prepared statements in close consultation with Hogan senior officials.
Weinman said the findings at Charlotte Hall were “widely known, well-documented, and subject to strong corrective action requirements. Governor Hogan’s administration took significant steps to hold the vendor accountable and correct documented deficiencies, while providing increased oversight.”
Russell Keogler, vice president of HMR of Maryland LLC, confirmed collaborating with the former administration as deficiencies were cited.
“HMR worked in partnership with the [veteran’s administration] under Governor Hogan’s administration to ensure any concerns were immediately addressed. Oversight increased during the pandemic, as in all nursing homes. Charlotte Hall Veterans Home remained in compliance with state and federal standards,” he wrote in a statement.
Former state treasurer ‘would have raised the issue’
A review of online inspection reports completed by the state’s Office of Health Care Quality and maintained by the Centers for Medicare and Medicaid Services revealed safety and quality of life citations occurred at Charlotte Hall years before the pandemic. And 2021 Board of Public Works records showed the state agency requested HMR’s contract be renewed months after a report revealed the facility failed to protect residents from sexual abuse by other residents.
But at the September 2021 Board meeting no member asked Owings or Charlotte Hall director Maria Cariaso about anything other than COVID-19 cases and a vaccination update. The spending board, which included Hogan, then-Treasurer Nancy Kopp and then-Comptroller Peter Franchot, unanimously approved the renewal.
When asked if she had been made aware of deficiencies at Charlotte Hall, Kopp, a Democrat, said, “The answer is no. I don’t remember seeing any report outlining the sort of things we’re reading about in the paper now.”
“We certainly would have raised the issue” but “it doesn’t mean that the conclusion would have been different,” she said, given the timing of the pandemic.
Messages left for Franchot, a Democrat, were not returned before publication.
What inspection reports reveal
Owings said he was aware of a few incidents from an August 2022 report, including one where the facility failed to adequately supervise patients with histories of aggressive behavior. Staff witnessed one resident “stomping” on the head of another resident, sending the latter to the hospital.
Owings said he was aware staff were cited for leaving medicine carts unlocked, something inspectors called an “immediate jeopardy to resident health or safety.”
“We kept admonishing all those that were on the floor at the time — lock your cart, lock your cart,” Owings recalled.
But these were just a few of many documented citations made by state inspectors.
According to a 2018 report, one patient, who experienced “confusion” and required supervision in order to smoke tobacco, lit their shirt on fire and suffered burns.
In the same report, a hospice patient told an inspector their call button was kept out of reach. “They always put it where I can’t find it so, I call out for help,” the patient said, according to the report.
A February 2020 inspection found the facility failed to treat a patient’s destructive behaviors and confusion, despite weeks of medical notes from doctors and nurses, “allowing the resident to worsen without explanation or treatment,” the report said.
In two incidents, the facility failed to keep residents safe from sexual abuse at the hands of a resident with a history of inappropriate sexual behavior, according to a 2021 report.
Again in early 2021, one resident, who suffered chronic leg wounds, told an inspector they understood it was their responsibility to change their own dressings. However, staff denied this was the case, saying the patient misunderstood their care plan, the report said.
Moore, legislators demand corrective action
The Moore administration is in the process of hiring a team of nurses to assess the wellness of Charlotte Hall residents and will seek a new contractor to operate and manage the home.
In budget language, the Maryland Senate requested the veterans affairs department submit quarterly reports tracking Charlotte Hall’s performance metrics, including incidents of abuse and neglect. Lawmakers are considering related legislation.
Senate President Bill Ferguson said during a Friday news conference he’ll “rely heavily on the secretary of veterans affairs to get a sense of whether or not legislation is required or this is something that administratively can be handled.”
Sen. Michael A. Jackson, a Democrat serving Calvert and Prince George’s counties and leader of the Maryland Veterans Caucus, said resolving the home’s challenges isn’t about pointing fingers.
“We all own this. ... we got to get to the root of exactly what the challenges are before we can move forward to address those challenges,” he said.
Keogler, with HMR, said the star rating is not a reflection of the care received by residents at Charlotte Hall and the company maintains its commitment to serving veterans and ensuring a smooth transition. Federal and state regulators defined the events as “isolated incidents,” Keogler said.
“It is important to know that HMR of Maryland has always operated under full transparency and immediately reported these incidents to the Office of Health Care Quality (OHCQ) for review,” Keogler wrote in an email. “In each instance, the home’s administration took swift and appropriate action and the surveying agency (OHCQ) agreed that appropriate actions were taken.”
Keogler said that because regular inspections were not performed during the pandemic and two isolated incidents in two sequential inspections, the veterans home automatically lost one star from their rating.
Keogler’s company is a state-level operator receiving management services and oversight from HMR Veterans Services, operating one of 12 homes in four states connected to the corporation.
HMR Veterans Services’ homes have been the subject of federal and state investigations. An Alabama operator was later cleared of allegations after a resident’s family came forward and whistleblowers reported patient neglect. A South Carolina operator allegedly failed to investigate claims of abuse and neglect, according to news reports.
HMR donated to Hogan, Moore, others
HMR Veterans Services has donated tens of thousands of dollars to notable Maryland politicians since 2006, including former Speaker of the House Michael E. Busch and former Senate President Thomas V. Mike Miller Jr.
Maryland’s campaign finance caps may have kept dollar figures low. But the timing of the donations and the recipients show the company knew their way around the state.
In 2014, HMR backed then-governor candidate Anthony Brown, a Democrat, when he ran against Hogan. Then, weeks before Election Day, the corporation donated to the Republican State Central Committee, and so did Michael H. McBride, the chairman of HMR’s board of directors.
The four top executives of HMR Veterans Services each donated $2,500 to Hogan’s reelection campaign one day after their employer donated $6,000 to the incumbent governor.
During this latest election cycle, HMR was an early giver to Franchot’s gubernatorial campaign, giving the maximum $6,000 in April of 2021. But the company shifted gears after then-candidate Wes Moore won the primary, and gave the soon-to-be-governor $5,000 in August 2022.
The Moore administration did not respond to a question asking if Moore would refund the donation. Hogan’s spokesperson did not respond to questions about the donations.
Keogler said the executives regularly donate to candidates in both parties who support veterans issues.
Overall, Owings said he was “proud” of Charlotte Hall Veterans Home, and he’s “not going to point fingers or lay blame anywhere.” He’s perplexed that HMR, an experienced and award-winning company, is being “called upon in this manner.”
“So I’m just wondering exactly what was going on down there,” Owings said.
“[I] actually had family there [at Charlotte Hall] as well,” he said. “If there were major problems, I would not have exposed any family members.”
When asked if he thought his team did enough to ensure patient safety and quality care for the veterans at Charlotte Hall, Owings responded, “It’s not our team. It’s HMR’s team. Our team is an oversight team from the state that reports to the board of directors.”
Owings said he has not been back to Charlotte Hall since he left his state job in January. But the retiree said his future plans have always included residing at the home.
When asked if that was still his plan, Owings responded, “I have no problem with going to Charlotte Hall. Depends on who the administrator is, I guess, how it’s being run.”