Atlee Hill Health And Rehab Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on record review and staff interviews, it was determined that the facility failed to notify an attending physician when there were documented changes in a Resident's condition. This was evident for 1 (#69) out of 15 Residents reviewed for Abuse.The findings include:A review of a facility-reported incident (#337746) revealed an allegation of Abuse made by Resident #69.A continued review revealed that staff #8, a licensed practical nurse (LPN), had reported to Resident #69's representative on 4/6/25 that the Resident was more confused and agitated today. The nurse continued to report that Resident #69 had thrown [his/her] dinner tray at her. However, the review failed to show that Resident #69's attending provider was notified of the change in behavior. In an interview on 8/28/2025 at 4:33 PM, the Director of Nursing (DON) stated that the change in Resident #69's behavior on 4/6/25 was considered a change in condition and, therefore, expected a change in condition assessment form to be completed and notification of Resident #69's attending provider of the change. However, an earlier record review failed to show that staff #8 completed a change in condition assessment for Resident #69 and notified his/her attending provider of the change in behavior.During a subsequent interview on 8/29/2025, at 8:10 AM, the DON verbalized understanding of

the concern regarding the failure to report a change in Resident #69's behavior to his/her provider.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the facility's abuse policy and interview it was determine that the facility failed to ensure

the abuse policy addressed all the required components. This was found to be evident for the one abuse policy and has the potential to affect all the residents.The findings include: This regulation was written to provide protections for the health, welfare and rights of each resident residing in the facility. In order to provide these protections, the facility must develop written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. These written policies must include, but are not limited to, the following components: Screening; Training ; Prevention; Investigation; Protection; and Reporting/response. On 8/26/25 review of the abuse policy, that was provided to the survey team at the start of the survey, failed to reveal a date that it was initiated or reviewed. On 8/26/25 at 10:43 AM the nursing home administrator (NHA) confirmed this was the abuse policy that is provided to staff. The policy included definitions of physical, sexual and verbal abuse, neglect and exploitation and included a list of some physical, behavioral and social signs of abuse. The policy failed to address misappropriation of resident property. The policy failed to address abuse prevention or training of staff. The policy failed to address coordination with the Quality Assurance Performance Improvement program. In regard to reporting abuse the policy stated: In the event that anyone in the facility (employee, visitor, family member, service provider, etc) has evidence or credible cause to believe that a resident has been subject to any or all of the above types of abuse, that person with knowledge is strongly encouraged to report in good faith all allegations, suspicions, or incidents to an administrative staff member, the Ombudsman or to the State officials as posted in the facility. A report may be made either in written or oral form should contain as much information as the reporter is able to provide Allegations of abuse and neglect will be reported to the Administrator within 24 hours of the allegation (8 hours for Washington DC) and initial report to the state agencies will be completed as per regulation. Federal regulation requires that allegations of abuse are reported immediately, but not later than 2 hours after the allegation is made, to the NHA and other officials. Cross reference to F 609. The policy failed to address prohibiting and preventing retaliation for reporting suspected abuse. On 8/26/25 at 1:00 PM observations made throughout the facility, including employee break areas, failed to reveal posted signage of employee rights related to retaliation against the employee for reporting a suspected crime. On 8/26/25 at 1:18 PM the NHA confirmed they do not have this specific signage posted in the facility. On 8/26/25 at 1:18 PM surveyor reviewed the concern with the NHA that the facility's abuse policy does not include all of the components required by the regulation.

Residents Affected - Many

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609

failure to report allegations of abuse in a timely manner.

Level of Harm - Minimal harm or potential for actual harm

4) A review of a facility-reported incident #2564116 related to Resident #10 showed that the resident reported an allegation of abuse to staff #17, a licensed practical nurse (LPN), on 7/12/25.

Residents Affected - Some

Further review of the facility's investigation into the allegation revealed that Resident #10 made the allegation to Staff #17 on 7/12/25, at 12:40 AM. The Nursing home administrator (NHA) was notified of the allegation on 7/14/25. The incident was initially reported to the state agency on 7/16/25 at 3:22 PM, two days after it had been reported to the facility.

During an interview with the Director of Nursing (DON) on 8/27/2025, at 4:52 PM, she mentioned that her expectation was for staff #17 to have reported the allegation to her immediately; however, this did not occur.

The DON verbalized understanding of the concern of not sending an initial report of the alleged abuse to

the state agency, but not later than 2 hours after the facility staff became aware of the allegation. 5) A review of a facility-reported incident #337744 contained an allegation made by Resident #71 on 2/25/25 of missing money from his/her room.

A continued review of the facility's investigation file revealed that the allegation of missing money was initially reported to the state agency on 2/28/25 at 5:44 PM.

The final report was completed on 3/11/25, at 2:25 PM, indicating that once the facility became aware of

the allegation, the staff failed to forward a first report to the state agency within two hours and a final report within five business days.

In an interview with the Nursing home administrator on 8/28/2025, at 5:13 PM, she verbalized understanding of the concern regarding not reporting the allegation of missing money to the office in a timely manner.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628

of the facility's bed hold policy and a transfer notice, along with the reason for the transfer.

Level of Harm - Minimal harm or potential for actual harm

In an interview on 8/25/2025, at 1:48 PM, the admissions director reported that she was responsible for mailing the facility's bed hold policy and transfer notice to residents' representatives. However, she only sent them to representatives of residents who were in the facility for a short stay, not to representatives of long-term residents.

Residents Affected - Few

During an interview with the nursing home administrator on 8/25/2025, at 2:07 PM, she reported that the facility had stopped mailing written bed hold policies and written transfer notices to the representatives of long-term care residents to avoid confusion.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-29.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to provide residents/representatives with a copy of their baseline care plan, which included a summary of the Resident's medication. This was evident for 2 (#14, #83) of 43 residents reviewed during the recertification survey.The findings include:A baseline care plan is a document that outlines initial instructions for providing care to a resident in a long-term care facility, typically developed within 48 hours of admission. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) In an interview on 8/19/2025, at 8:49 AM, Resident #14's representative stated that he had not received

a copy of the Resident's baseline care plan, including a list of his/her medications.

A record review on 8/21/2025, at 10:52 AM, showed that Resident #14 was admitted to the facility on [DATE REDACTED]. A continued review revealed that a baseline care plan dated 8/6/25 for Resident #14 had been initiated but was not completed. The review also contained another baseline care plan, dated 8/8/25, for Resident #14 that had been started and marked as complete, but was missing the staff and representative's signatures.

In an interview with the director of nursing on 8/21/2025, at 2:24 PM, she reported that there was no documentation to show that a copy of Resident #14's baseline care plan, including a list of his/her medications, was given to the representative. 2) Resident #83 was admitted to the facility on [DATE REDACTED], for therapy following a hospitalization. Review of complaint #337726 revealed a concern that the first care plan meeting was held 15 days following admission, and this meeting was the first time the level of care required was communicated to the family.

Review of the Baseline Care Plan, signed as completed by the registered dietician (RD#) and nurse #12, revealed the resident was cognitively impaired and confused. Further review of the Baseline Care Plan revealed that a copy was given to the resident on 5/9/24. The area of the form to document the resident representative's signature was noted to be blank. Further review of the medical record failed to reveal documentation to indicate that a copy of the baseline care plan was provided to the resident's representative.

Further review of the medical record revealed a note written by the Social Service Director (SSD #1) on 5/23/24, which revealed the interdisciplinary team met with the resident and the family on that date for admission care plan meeting.

On 8/26/25, at 3:37 PM, when asked who provides the baseline care plan, the Social Service Director (SSD #1) reported she believed nursing does.On 8/26/25, at 5:34 PM, the surveyor reviewed the concern with the Director of Nursing (DON) that the family had not been provided a copy of the baseline care plan. DON reported it was provided to the resident.

As of the time of survey exit on 8/29/25, no documentation was provided to indicate that the baseline care plan had been provided to the family.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

assists with ordering Durable Medical Equipment and Home Health Care as part of discharge planning. No documentation was found in the care plan in regard to facilitating the identification of an appropriate discharge location or assisting with obtaining needed supplies or services upon discharge. On 8/29/2025 at 10:05 AM surveyor reviewed the concern with the Director of Nursing (DON) that the resident's care plan for discharge on ly included that staff would discuss discharge needs with the family. DON acknowledged

the concern.

Cross reference to F 628 3) Resident #76 was admitted to the facility in January 2025. Review of the admission Minimum Data Set (MDS) assessment, with an assessment date of 1/19/25, revealed that the resident was occasionally incontinent of urine. Review of the Care Area Assessment (CAA) Summary section of the MDS revealed the care area of urinary incontinence had triggered and a decision was made to address urinary incontinence in a care plan. Review of the care plans for Resident #76 failed to reveal incontinence was addressed in a care plan. On 8/25/25 at 3:51 PM the Director of Nursing (DON) reported that, in regard to the CAAs, the idea is to set the care plan up for whatever the trigger is. Surveyor reviewed

the concern that the CAA indicated a care plan would be developed to address urinary incontinence, but none was found. The DON confirmed that she did not see a care plan addressing the urinary incontinence.

A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. Staff utilize care plans to provide resident-centered care that includes support, services, and resources tailored to address each Resident's specific needs.

The Minimum Data Set (MDS) is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-29.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADL) was provided with showers. This was evident for 1 (#48) of 3 Residents reviewed for ADLs. The findings include:In an interview with Resident #48 on 8/19/2025 at 3:11 PM, s/he indicated that s/he would like to get more showers than were offered as of the time of the interview.A record review showed that Resident #48 had been in the facility since June 2025. A continued

review included an MDS assessment dated [DATE REDACTED], for Resident #48, which recorded that the resident required staff assistance with showering.The Minimum Data Set (MDS) is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs.

The information collected drives resident care planning decisions.A subsequent record review on 8/25/25, at 3:14 PM, of the GNA (Geriatric Nurse Aid) shower documentation from July 2025 to August 2025, noted no showers for July and one shower for August. An interview later that day with staff #20, a Geriatric Nurse aid (GNA), revealed that Resident #48 was scheduled to have two showers per week; however, an earlier

record review noted only one shower from July 1, 2025, to August 25, 2025.In an interview on 8/25/2025, at 4:15 PM, the Director of Nursing reported that Resident #48 had a shower on 8/19/25. The DON confirmed

the lack of documentation for the resident's showers for the other days from July 1, 2025, to August 25,

1. 2025. Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

Review of the TAR revealed these weights were due to be obtained on 1/27 and 2/3/25. No documentation was found to indicate weights were obtained, as ordered, on 1/27 or 2/3/25. Nursing staff documented NA indicating not applicable in the space to document the weight on 2/3/25. Further review of the medical

record failed to reveal documentation to indicate a weight was obtained, or attempted to be obtained, between 1/21/25 and the resident's discharge in February.

Residents Affected - Few

On 8/25/25 at 3:03 PM surveyor reviewed the concern with the Director of Nursing (DON) that there were orders for weights that were not obtained. The DON responded: I don't know what happened to the one on

the 27th. Surveyor also informed the DON that no documentation was found for the weight on the second day of admission.

As of time of survey exit on 8/29/25 no additional documentation was provided to indicate additional weights were obtained during the resident's admission.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-29.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

F 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident received their medication according to the attending physician's order. This was evident for one out of 5 complaints reviewed during the survey.The findings include:A review of complaint #337738 contained an allegation that staff failed to assess and give medication to Resident #75 when s/he complained of chest pain.A continued review showed that the Resident's medical history included chest pain secondary to unstable angina and had an attending provider's order to have Nitroglycerin Tablet Sublingual 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for Chest Pain x 3 doses.Further review included a nurse's note dated 10/19/24 that stated Reported from previous shift that Resident [complained] of chest pain through the night. She was given prn Zofran. The review failed to show that Resident #75 was given Nitroglycerin when s/he complained of chest pain.In an interview on 8/28/2025 at 3:57 PM, Staff #10, Registered nurse (RN), reported that she had gotten a report on the morning of 10/19/24 from the outgoing nurse that Resident #75 had complained of chest pain during the night and was given an antiemetic drug.During an interview on 8/29/2025, at 11:10 AM, the Director of Nursing stated that Resident #75 had

an attending provider's order for a drug for chest pain. So, she expected that her staff would have given Resident #75 his/her angina medicine when s/he complained of chest pain and not an antiemetic drug.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Atlee Hill Health and Rehab Center

297 Stoner Avenue Westminster, MD 21157

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-08-29.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on record review, observations, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated their preferences.

This deficient practice has the potential to affect all residents. The findings include:A review of complaint #337742 revealed an allegation that the meals delivered to the residents did not match what was stated on

the menu.While observing the breakfast tray line on 8/26/2025, at 7:39 AM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #46. The listed food items on the meal ticket to be served to Resident #46 were: 3 oz biscuit with sausage gravy, 6 oz Cheerios, 6 oz orange Juice, 8 oz 2% milk, one bottle of water, pepper, and two packets of sugar.However, continued observation failed to show that Resident #46's tray contained the portion sizes listed on the meal ticket for the resident's Cheerios and orange juice. Staff #23, the Dietary Director, was present and asked about the portion size for the Cheerios and orange juice. Staff #23 measured the Cheerios with a 6 0z measuring spoon and said it was 5 oz instead of 6oz. Staff #23 also measured the orange juice with a measuring cup and said it was 4.5 oz instead of 6 oz.In an interview, Staff #23 stated that before the surveyor's intervention, his staff was not aware that the cup they served residents' juice with was not an 8-oz cup but a 4.5-oz cup. Staff continued to state he would place an order for the right size of cups. Staff #23 verbalized understanding regarding the concern of not serving Resident #46 the correct portion size as noted on his/her meal ticket.

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-29.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-29.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-29.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-29.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.

Federal health inspectors cited ATLEE HILL HEALTH AND REHAB CENTER in WESTMINSTER, MD for a deficiency under regulatory tag F-F0944 during a standard health inspection conducted on 2025-08-29.

Category: Administration Deficiencies

The facility was found deficient in the following area: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 19 deficiencies cited during this inspection of ATLEE HILL HEALTH AND REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-26.