Atlee Hill Health and Rehab: Care Plan Failures - MD
Federal inspectors documented the failure in an August 2025 complaint survey at the facility on Stoner Avenue. They found that Atlee Hill had failed to provide two residents, identified in the report as Resident #14 and Resident #83, with copies of their baseline care plans, which include a summary of medications prescribed at admission. The document is supposed to reach residents and their families within 48 hours of arrival.
For Resident #14, the representative told an inspector on August 19 that he had never received a copy of the care plan or a medication list. When inspectors pulled the records four days later, they found the facility had started two separate baseline care plans for the resident. The first, dated August 6, had been initiated but never completed. The second, dated August 8, was marked complete, but neither the staff nor the representative had signed it. The director of nursing, interviewed that afternoon, confirmed there was no documentation showing the plan had ever been handed over.
Resident #83's situation stretched back further and cut deeper. The resident had been admitted for therapy following a hospitalization and was cognitively impaired and confused, according to the baseline care plan itself. A copy of that plan had been given to the resident on May 9, 2024. The line where a family representative was supposed to sign was blank. Inspectors found nothing in the medical record to show the representative had ever received it.
The first time the family learned what level of care their relative required was at a care plan meeting held 15 days after admission, according to a complaint filed about the case.
A note from the Social Service Director, written on May 23, 2024, documented that the interdisciplinary team had met with the resident and family that day for an admission care plan meeting. That was two weeks after the resident arrived.
When a surveyor asked the Social Service Director who was responsible for providing the baseline care plan, she said she believed nursing handled it. When the Director of Nursing was asked about Resident #83's family not receiving a copy, she said it had been provided to the resident. The resident, the record showed, was cognitively impaired and confused.
No documentation was produced before inspectors left the facility on August 29 to show the family had ever received anything.
The baseline care plan is not a bureaucratic formality. It is the document that tells a family what their relative is being given, what conditions are being managed, and what the initial plan for care looks like. For a family member who cannot be present at every shift change, every medication administration, every clinical decision, it is often the only window into what is actually happening. When a resident is cognitively impaired and cannot speak for themselves, that window matters more.
Inspectors rated the harm level as minimal, and the violation affected a small number of the 43 residents reviewed. But the pattern the report describes is not a clerical slip. Two residents. Two sets of missing signatures. A Social Service Director uncertain whose job it was. A Director of Nursing who pointed to a confused resident as evidence the family had been informed.
The representative for Resident #14 had to tell an inspector, more than two weeks after his relative was admitted, that nobody had ever shown him the medication list.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Atlee Hill Health and Rehab Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD was cited for violations during a health inspection on August 29, 2025.
Federal inspectors documented the failure in an August 2025 complaint survey at the facility on Stoner Avenue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.