The Vardell Report.Atlee Hill Health and Rehab Center

Across 3 inspections from April 2019 to August 2025, state surveyors documented 67 findings at Atlee Hill Health and Rehab Center; 67 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

3

2019–2025, standard

Findings

67

Deficiencies cited by state inspectors

Corrected

67

Of 67 findings, with a recorded correction date

Penalties

2

1 fine; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 292025

   Standard health inspection

   19 findings

   The same visit included a complaint investigation.

   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level FNo actual harm, potential for moreCorrected Sep 26, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 26, 2025
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 26, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Sep 26, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 26, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Sep 26, 2025
   • F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Level ENo actual harm, potential for moreCorrected Sep 26, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F803Ensure 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.Level DNo actual harm, potential for moreCorrected Sep 26, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Sep 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Dec 212023

   Standard health inspection

   21 findings

   The same visit included a complaint investigation.

   • F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected Feb 11, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 14, 2024
   • F814Dispose of garbage and refuse properly.Level FNo actual harm, potential for moreCorrected Feb 14, 2024
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Feb 14, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Feb 14, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 14, 2024
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Feb 14, 2024
   • F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level CPotential for minimal harmCorrected Feb 14, 2024

   Enforcement Action

   Civil money penalty, $14,888 imposed December 21, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 21, 2023, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed January 2, 2024. Status: Closed, April 8, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 21, 2023, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Apr 192019

   Standard health inspection

   27 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level FNo actual harm, potential for moreCorrected Jun 24, 2019
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Jun 24, 2019
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 24, 2019
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jun 24, 2019
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level BPotential for minimal harmCorrected Jun 24, 2019
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level BPotential for minimal harmCorrected Jun 24, 2019
   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level BPotential for minimal harmCorrected Jun 24, 2019
   • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level BPotential for minimal harmCorrected Jun 24, 2019
   • F732Post nurse staffing information every day.Level BPotential for minimal harmCorrected Jun 24, 2019

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   The First 48 Hours, Cited in Three Inspections

   Inspectors cited F655 in April 2019, December 2023 and August 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F655 across all 3 inspections, oldest to newest
2. 2

   Care Plans, Cited in Three Inspections

   Inspectors cited F656 in April 2019, December 2023 and August 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F656 across all 3 inspections, oldest to newest
3. 3

   Medication Error Rate, Cited in Three Inspections

   Inspectors cited F759 in April 2019, December 2023 and August 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F759 across all 3 inspections, oldest to newest
4. 4

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in April 2019, December 2023 and August 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F812 across all 3 inspections, oldest to newest
5. 5

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in April 2019, December 2023 and August 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F880 across all 3 inspections, oldest to newest
6. 6

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in April 2019 and August 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F580 across all 3 inspections, oldest to newest
7. 7

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in December 2023 and August 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F609 across all 3 inspections, oldest to newest
8. 8

   Notice Before Transfer or Discharge, Cited in Two Inspections

   Inspectors cited F623 in April 2019 and December 2023. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F623 across all 3 inspections, oldest to newest
9. 9

   Citation F625, Cited in Two Inspections

   Inspectors cited F625 in April 2019 and December 2023. The agency describes it this way: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   192325F625 across all 3 inspections, oldest to newest
10. 10

    Accurate Assessments, Cited in Two Inspections

    Inspectors cited F641 in April 2019 and August 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F641 across all 3 inspections, oldest to newest
11. 11

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in April 2019 and December 2023. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F657 across all 3 inspections, oldest to newest
12. 12

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in April 2019 and August 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F684 across all 3 inspections, oldest to newest
13. 13

    Citation F756, Cited in Two Inspections

    Inspectors cited F756 in April 2019 and December 2023. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F756 across all 3 inspections, oldest to newest
14. 14

    Citation F757, Cited in Two Inspections

    Inspectors cited F757 in April 2019 and August 2025. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F757 across all 3 inspections, oldest to newest
15. 15

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in April 2019 and December 2023. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F758 across all 3 inspections, oldest to newest
16. 16

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in April 2019 and December 2023. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F761 across all 3 inspections, oldest to newest
17. 17

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in April 2019 and August 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F842 across all 3 inspections, oldest to newest
18. 18

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in April 2019 and August 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    192325F883 across all 3 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What happens in the first 48 hours after admission, and who writes the first care plan?

   The First 48 Hours: cited in three inspections, most seriously at level E.

2. 02

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in three inspections, most seriously at level E.

3. 03

   How are medication passes checked, and what happens when an error is found?

   Medication Error Rate: cited in three inspections, most seriously at level D.

4. 04

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

5. 05

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

6. 06

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level D.

7. 07

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in two inspections, most seriously at level E.

8. 08

   When do you transfer or discharge a resident, and how much notice do families get?

   Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.

9. 09

   What changed after F625 was cited, and how do you check it now?

   Citation F625: cited in two inspections, most seriously at level D.

10. 10

    Who completes resident assessments, and how are they checked for accuracy?

    Accurate Assessments: cited in two inspections, most seriously at level E.

11. 11

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level F.

12. 12

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level E.

13. 13

    What changed after F756 was cited, and how do you check it now?

    Citation F756: cited in two inspections, most seriously at level D.

14. 14

    What changed after F757 was cited, and how do you check it now?

    Citation F757: cited in two inspections, most seriously at level E.

15. 15

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level D.

16. 16

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level D.

17. 17

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level E.

18. 18

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level D.

19. 19

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

20. 20

    What led to the 2024 denial of payment, and what would you want a family to know about it?

    Denial of payment was imposed January 2, 2024; it ended April 8, 2024. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Maryland state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Apr 19, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Dec 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Maryland state survey agency

  Inspection Aug 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 215247

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.