Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Atlee Hill Health And Rehab Center during CMS and state inspections, most recent first.
A review of the facility's abuse policy and staff interviews revealed that the policy did not address all required elements, including misappropriation of resident property, abuse prevention, staff training, QAPI coordination, and timely reporting requirements. The policy also failed to prohibit retaliation for reporting suspected abuse, and there was no posted signage informing employees of their rights regarding retaliation.
Improper food labeling and expired items were found in the kitchen and a nutrition room refrigerator. Multiple prepared foods lacked required prep or use-by dates, several items were kept past their use-by dates, and expired thickened juices were found in the unit refrigerator. The dietary director and DON identified that dietary staff were responsible for these areas, and the dietary director stated staff had not yet been trained on the new labeling process.
Infection prevention and control was deficient because the facility did not have a water management system to identify Legionella and other waterborne germs, and staff interviews showed no prior Legionella risk assessment or water plan had been completed. The facility also had ten wall-mounted hand sanitizer dispensers in resident and staff areas that were expired, which the DON confirmed during the tour.
The facility did not report multiple allegations of abuse, neglect, or theft to the state agency or law enforcement within the required timeframes. In several cases, residents reported incidents to staff, but there were delays in notifying facility leadership and external authorities, despite facility policy and regulatory requirements. Interviews confirmed that staff were aware of the reporting requirements, but documentation showed repeated failures to comply.
Surveyors found that the facility did not consistently develop or implement comprehensive, person-centered care plans for three residents. One resident's need for ADL assistance was not addressed in their care plan, another resident's discharge planning lacked documentation of assistance with ALF placement and necessary supplies, and a third resident's urinary incontinence was not included in their care plan despite assessment triggers. The DON and social services staff confirmed these omissions during interviews.
Failure to document ordered medications and treatments for a resident with HTN, dysphagia, bladder dysfunction requiring a catheter, dementia, anxiety, and depression. The MAR/TAR had multiple blank entries for meds and treatments, including pain checks, Foley catheter flushing, skin assessment, barrier precautions, and psychotropic side effect monitoring. The DON confirmed blank entries meant care was not documented as done or not done and acknowledged the gaps appeared to show care was not performed.
The facility failed to provide QAPI training to staff. A review of employee education files for five staff members found no evidence of training on the facility’s QAPI program, and the NHA stated she could not produce current documentation showing that staff had been trained on the program’s elements and goals.
A resident exhibited increased confusion and agitation, including throwing a dinner tray, which was reported by an LPN to the resident's representative but not to the attending physician. The DON confirmed that this behavioral change should have prompted a change in condition assessment and provider notification, but documentation of these actions was lacking.
The facility failed to ensure accurate communication and documentation during resident transitions, including providing incomplete or inaccurate assessment information to a receiving ALF, not processing or documenting orders for medical equipment and home health services as discussed, and not providing required written transfer notices or bed hold policies to residents' representatives during transfers to acute care.
Two residents and their representatives did not receive a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission. In both cases, documentation was incomplete or missing, and staff interviews revealed uncertainty about responsibility for providing this information.
A resident who required staff assistance for showering did not receive the scheduled number of showers, with records showing only one shower provided over nearly two months. The resident expressed a desire for more frequent showers, and staff confirmed the lack of documentation for additional showers during this period.
Three residents experienced deficiencies in care: one received an incorrect dose of Carvedilol due to a transcription error and lack of proper admission checks, resulting in hypotension and hospitalization; another was given an antiemetic instead of prescribed nitroglycerin for chest pain, with no assessment or provider notification; and a third did not have required weights obtained or documented as ordered, with no explanation for the omissions.
A resident with a history of unstable angina did not receive prescribed Nitroglycerin for chest pain as ordered by the provider. Instead, staff administered an antiemetic (Zofran) when the resident complained of chest pain, and documentation did not show that the correct medication was given.
A resident was served breakfast with incorrect portion sizes for cereal and juice, as the items provided did not match the amounts listed on the meal ticket. The Dietary Director confirmed that staff were unaware the cups used for juice were smaller than required, resulting in residents not receiving the correct portions as specified on the menu.
Inaccurate MDS Assessments: The facility failed to ensure MDS assessments were accurate for three residents. One resident’s MDS incorrectly documented insulin use despite no MAR or provider order supporting it. Another resident with PAD, DM2, heart disease, and pressure ulcers had a new schizoaffective disorder diagnosis entered even though the psychiatric note described the resident as stable with no psychosis, hallucinations, delusions, or mood instability. A third resident’s MDS changed an active diagnosis to schizophrenia without supporting documentation, and the CRNP later said the diagnosis should not have been entered.
Unsupported Schizoaffective Disorder Diagnosis: A resident with depression, dementia, and bipolar disorder was also documented as having schizoaffective disorder, which was used to support risperidone therapy. However, psychiatric notes described the resident as stable with no psychosis, hallucinations, delusions, or mood instability, and the CRNP could not point to record evidence supporting the added diagnosis. The CRNP later stated the diagnosis should not have been entered and was likely a typographical error.
Delayed treatment for a stage 3 pressure ulcer was identified for a resident admitted with an open sacral wound present on admission. The wound was documented as a right buttock/sacrum stage 3 pressure sore, but the order summary showed no wound treatment was implemented until 7 days after admission; the DON confirmed staff had only applied incontinence care cream every shift before treatment began.
A medication pass for a resident resulted in two omitted scheduled meds, acetaminophen and meclizine, during an observed administration. The CMA gave six ordered meds but failed to administer or document the two 9:00 AM doses, and the MAR review showed the resident had received morning acetaminophen on 6 of the prior 7 mornings. These omissions produced an 8% med error rate, exceeding the required threshold.
A resident’s immunization record lacked evidence that the pneumonia vaccine was offered, explained, received, or declined. The surveyor reviewed the record and asked the DON for documentation, but the DON could not provide proof and stated the admission process should have included the required education and offer.
Abuse Policy Lacks Required Components and Protections
Penalty
Summary
The facility failed to ensure its abuse policy addressed all required regulatory components, as determined by a review of the policy and interviews with staff. The policy lacked a date of initiation or review and, while it included definitions of various types of abuse and some signs of abuse, it did not address misappropriation of resident property. Additionally, the policy did not include provisions for abuse prevention, staff training, or coordination with the Quality Assurance Performance Improvement (QAPI) program. The reporting section of the policy did not meet federal requirements, as it did not specify that allegations of abuse must be reported immediately, but not later than two hours after the allegation is made, to the nursing home administrator and other officials. Furthermore, the policy failed to address the prohibition and prevention of retaliation against individuals reporting suspected abuse. Observations throughout the facility, including employee break areas, revealed that there was no posted signage informing employees of their rights related to protection from retaliation for reporting suspected crimes. The nursing home administrator confirmed the absence of such signage and acknowledged that the abuse policy provided to staff was incomplete in these areas.
Improper Food Labeling and Expired Items in Refrigerators
Penalty
Summary
Food was not stored in accordance with professional standards in the facility kitchen and in a nutrition room refrigerator. During an initial tour with the dietary director, multiple items were found in the walk-in refrigerator and freezer with missing or incorrect preparation and use-by dates, including leftover roast beef dated 3/18/25 with a use-by date of 3/21/25, tortellini pasta salad dated 8/13/25 with no use-by date, roasted turkey dated 8/6/25 with no use-by date, diced chicken with a use-by date of 8/12/25 and no preparation date, ham salad dated 8/15/25 with a use-by date of 8/18/25, chicken salad dated 8/13/25, peanut sauce dated 8/13/25 with no use-by date, cooked rice dated 8/14/25 with no use-by date, sweet cream cheese dated 8/13/25 with no use-by date, and mixed vegetables with no use-by date. The dietary director stated some of the items should have been discarded earlier and identified that labeling concerns had already been noted, but staff had not yet been trained on the new labeling process. In a separate observation of the nutrition room refrigerator, expired thickened apple juice and thickened orange juice were found with use-by dates of 7/3/25 and 6/4/25. A RN confirmed the items were expired and discarded them after the surveyor’s intervention. The DON stated that dietary staff were responsible for cleaning and discarding expired items from the unit refrigerator, and the dietary director later stated he had just learned that dietary staff were responsible for stocking and cleaning the nutrition room refrigerator and had begun educating staff about this.
Infection Prevention Program Lacked Water Management Plan and Expired Hand Sanitizer Dispensers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have a water management system in place to identify Legionella and other harmful waterborne germs in the building. During interviews, the DON stated she was temporarily filling the Infection Preventionist role after the ADON left, and later stated that the ESD was likely responsible for managing water risks. The facility risk assessment contained Legionella test results from Fountain Valley Analytical Lab, with water samples collected on two dates and all results negative, but no completed water management plan or risk assessment was available when the NHA was asked to show how testing locations were determined. Further interviews showed that the NHA initially believed Fountain Valley had conducted a risk assessment, but the ESD stated he had not conducted one or created a water management system and later confirmed that no type of assessment had been completed. The NHA and ESD later stated they had found a Legionella toolkit and were working on an assessment, and the NHA acknowledged that the facility had not previously had a Legionella risk assessment or water plan. The facility also failed to ensure that wall-mounted hand sanitizing dispensers in resident and staff areas were maintained within their expiration dates; during a tour, ten dispensers in both units were observed with February 2024 expiration dates, and the DON confirmed they were expired and removed them for disposal.
Failure to Timely Report Allegations of Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner for multiple residents, as evidenced by record review and staff interviews. In several cases, allegations were either not reported to the state agency within the required timeframe or not reported to law enforcement as appropriate. For example, one resident with complex medical needs, including hydrocephalus and chronic kidney disease, reported an incident involving a blood draw that was perceived as abusive. The DON was notified by the resident’s family, but the incident was not reported to the state agency until two days later, exceeding the required reporting window. Another instance involved a cognitively intact resident who reported theft of money to a receptionist, who then informed the DON. The DON initiated an internal investigation and interviewed staff, but the incident was not reported to the state office until the following day, and law enforcement was not notified. Additional cases included residents reporting abuse or missing money to staff, with delays in both internal notification to facility leadership and external reporting to the state agency. In one case, a resident’s allegation of abuse was reported to an LPN, but the NHA was not notified until two days later, and the state agency was not informed until four days after the initial report. Facility policy required allegations to be reported to the administrator within 24 hours and to state agencies as per regulations, which in some cases is within two hours. Interviews with the NHA and DON confirmed awareness of these requirements, but documentation and investigation records showed repeated failures to meet the mandated reporting timelines. These deficiencies were identified for five residents out of fifteen reviewed for abuse allegations.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, as evidenced by medical record reviews and staff interviews. One resident, who required assistance with activities of daily living (ADLs) as documented in the Minimum Data Set (MDS), did not have these needs addressed in their care plan. The Director of Nursing (DON) confirmed that the care plan was not comprehensive and did not capture the resident's ADL needs. Another resident, admitted for therapy and with a goal of discharge to an assisted living facility (ALF), had a care plan that only included staff discussing discharge needs with the family. There was no documentation in the care plan regarding assistance with identifying an appropriate ALF placement or obtaining necessary supplies and services for discharge, despite the responsible party's stated goals and the social worker's reported practices. A third resident, who was occasionally incontinent of urine according to the admission MDS assessment, had triggered a care area assessment (CAA) for urinary incontinence, with a decision to address this in a care plan. However, review of the care plans revealed that urinary incontinence was not addressed. The DON confirmed that the care plan did not include interventions for urinary incontinence, despite the CAA indicating it should be addressed. These findings demonstrate that the facility did not consistently develop or implement care plans that addressed all identified resident needs.
Failure to Document Ordered Medications and Treatments
Penalty
Summary
The facility failed to accurately document care in Resident #36’s medical record. Resident #36 had a history of hypertension, dysphagia, bladder dysfunction requiring a catheter, dementia, anxiety, and depression. On review of the Medication and Treatment Order records, multiple ordered medications and treatments were left blank, including medications due on 8/9/2025 and several treatments such as pain evaluation each shift, antifungal powder application, Foley catheter flushing with normal saline, pressure-reducing cushion use when out of bed, observation for changes in physical or mental status each shift, enhanced barrier precautions, behavioral occurrence counts, and monitoring for psychotropic medication side effects. The surveyor interviewed the DON, who stated that blank boxes meant the care was not documented as done or not done. The DON agreed the missing documentation was concerning and acknowledged that the gaps appeared to show care was not performed. Later, the DON reported that her audit of the wing’s August 2025 records showed all of the missed documentation was linked to one nurse, and she identified that 30 other residents were also affected by that nurse not documenting care as ordered.
Missing QAPI Training for Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to employees. During a review of employee education files, the surveyor examined Staff #12, #13, #14, #15, and #16 and found no evidence that they had received training on the facility’s QAPI program. The Nursing Home Administrator stated that QAPI training had been provided at one point but could not produce current evidence of it, later explaining that the training had been done quite a while ago and that there was nothing current to show. She also stated that she was not aware it was a mandatory requirement to provide training that outlines the facility QAPI program and informs staff of the elements and goals of the program.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify an attending physician of a documented change in a resident's condition. Specifically, a licensed practical nurse (LPN) observed that a resident was more confused and agitated, and reported this change in behavior, including the resident throwing a dinner tray, to the resident's representative. However, there was no evidence that the LPN completed a change in condition assessment or notified the resident's attending provider of these behavioral changes. The Director of Nursing (DON) confirmed that such a change in behavior should have triggered both an assessment and provider notification, but the records did not show that these actions were taken.
Deficiencies in Transition of Care Communication and Required Written Notifications
Penalty
Summary
The facility failed to ensure appropriate communication and documentation during resident transitions, resulting in deficiencies related to discharge planning and notification requirements. For one resident discharged to an assisted living facility (ALF), the care plan lacked documentation on facilitating the identification of an appropriate discharge location and assistance with obtaining necessary supplies and services. The Resident Assessment Tool (RAT) provided to the ALF contained inaccurate information regarding the resident's continence and psychosocial status, which did not align with the Minimum Data Set (MDS) and other clinical documentation. Additionally, there was no evidence that the facility processed orders for durable medical equipment or home health care as discussed in care plan meetings, and the discharge instructions form was incomplete regarding medical equipment arrangements. Further review revealed that although discharge orders for skilled nursing, physical and occupational therapy, and a home health aide were documented, there was no evidence that these orders or referrals were communicated to the receiving ALF. The facility also failed to document that discharge orders were sent to the ALF, and the Maryland Discharge Instructions form did not reflect the home health or therapy orders. Interviews with staff confirmed that some equipment orders were not placed as indicated, and home health services were not ordered because the ALF had its own therapy department, but this was not documented in the resident's record. In a separate incident, another resident was transferred to an acute care facility due to a change in condition. The resident's representative was notified by telephone, but there was no documentation that a written transfer notice or the facility's bed hold policy was provided as required. The admissions director stated that written notifications were only sent to short-stay residents' representatives, and the nursing home administrator confirmed that the facility had stopped mailing these documents to long-term care residents' representatives to avoid confusion. This resulted in a failure to provide required written notifications during the transfer process.
Failure to Provide Baseline Care Plan and Medication Summary to Residents/Representatives
Penalty
Summary
The facility failed to provide residents or their representatives with a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission as required. For one resident, the representative reported not receiving the baseline care plan or medication list, and record review confirmed that while a care plan was initiated and later marked as complete, it lacked both staff and representative signatures. There was no documentation to show that the representative had been given a copy of the care plan or medication summary. For another resident admitted for therapy after hospitalization, the baseline care plan was provided to the resident but not to the representative, as indicated by a blank signature area and lack of documentation in the medical record. The first care plan meeting with the family occurred 15 days after admission, which was the first time the level of care was communicated to them. Staff interviews revealed confusion about who was responsible for providing the baseline care plan to representatives, and no documentation was provided to confirm that the representative received the required information.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance with activities of daily living, specifically showering, was not provided with the scheduled number of showers. The resident, who had been in the facility since June 2025, expressed a desire for more frequent showers during an interview. Review of the Minimum Data Set (MDS) assessment confirmed the resident's need for staff assistance with showering. Documentation from July to August 2025 showed no showers in July and only one shower in August, despite the resident being scheduled for two showers per week. Staff interviews confirmed the resident's shower schedule and the lack of documentation for showers provided during this period. The Director of Nursing acknowledged that only one shower was documented between July 1 and August 25, 2025.
Failure to Provide Care According to Physician Orders and Professional Standards
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, atrial fibrillation, and hypertension was admitted following a hospitalization for dyspnea. Upon admission, the facility transcribed a hospital order for Carvedilol incorrectly, entering it as 25 mg twice daily instead of the intended 12.5 mg (half tablet) twice daily. This error resulted in the resident receiving double the prescribed dose for four administrations, leading to hypotension, acute kidney injury, and a transfer to the hospital. The facility's admission process was not followed, as the required admission checklist and second nurse review were not completed, and the error was not identified by the pharmacist during the admission medication review. Another deficiency was identified when a resident with a history of unstable angina and an order for sublingual nitroglycerin for chest pain reported chest pain during the night. Instead of administering the prescribed nitroglycerin, staff gave the resident an antiemetic (Zofran) and did not assess the resident for a change in condition or notify the attending provider. The resident later requested transfer to the hospital for evaluation of a possible heart attack due to their medical history. A third deficiency involved a resident admitted after a hospitalization, for whom the facility failed to obtain and document weights as ordered. The resident's care plan and physician orders required weights to be taken on admission, on day two, and weekly for four weeks. Documentation showed that weights were not obtained or recorded on the required days, and there was no evidence that attempts were made to obtain the missing weights. The DON was unable to account for the missing documentation or explain why the required weights were not obtained.
Failure to Administer Prescribed Medication for Chest Pain
Penalty
Summary
A deficiency was identified when a resident with a medical history of chest pain secondary to unstable angina did not receive medication as ordered by the attending provider. The provider's order specified that Nitroglycerin Tablet Sublingual 0.4 MG should be administered sublingually every 5 minutes as needed for chest pain, up to three doses. Record review and staff interviews revealed that when the resident complained of chest pain during the night, staff administered an antiemetic (Zofran) instead of the prescribed Nitroglycerin. Documentation did not show that the Nitroglycerin was given, and both the RN and the Director of Nursing confirmed that the resident should have received the angina medication according to the provider's order.
Failure to Serve Meals According to Menu and Portion Sizes
Penalty
Summary
The facility failed to serve meals to residents according to the predetermined menu and specified portion sizes, as required. During a surveyor's observation of the breakfast tray line, a test tray prepared for a resident did not contain the correct portion sizes for Cheerios and orange juice as listed on the resident's meal ticket. The Cheerios portion was measured at 5 oz instead of the required 6 oz, and the orange juice was measured at 4.5 oz instead of 6 oz. The Dietary Director confirmed that the cups used for serving juice were not the correct size, and staff were unaware of this discrepancy prior to the surveyor's intervention. This deficiency was identified through record review, observation, and staff interview, and it was determined that the practice had the potential to affect all residents.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for 3 of 43 residents reviewed. The report states that MDS assessments must be accurate because they are used to develop care plans, deliver appropriate care and services, and modify care based on resident status. The deficiencies involved inaccurate documentation in the MDS for medication use, active diagnoses, and a new psychiatric diagnosis that was not supported by the resident record. For one resident, an MDS assessment recorded 2 days of insulin injections, but review of the MARs for the observation period showed no insulin documentation and no current provider order for insulin during that look-back period. The MDS Coordinator stated that MARs were her source for medication documentation, and the record review showed the MDS entry was recorded in error. For another resident with PAD, heart disease, type 2 diabetes, and pressure ulcers, the surveyor reviewed the MDS and psychiatric records and found that a new diagnosis of schizoaffective disorder, bipolar type had been added despite a progress note stating the resident was stable with no psychosis, hallucinations, delusions, or mood instability. For the third resident, the MDS Section I active diagnoses changed from no schizophrenia to schizophrenia on a later assessment. The surveyor reviewed the psychiatric note supporting the change and found that the note documented the resident as stable while listing schizoaffective disorder, bipolar type as a new diagnosis. The CRNP later stated the diagnosis should not have been entered and was likely a typographical error. The MDS Nurse Coordinator and DON acknowledged that if the diagnosis was not accurate, the MDS would also be inaccurate.
Unsupported Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to provide evidence to support a diagnosis of schizoaffective disorder for one resident reviewed for unnecessary medications. The resident had a documented history of major depression, dementia, bipolar disorder, and schizoaffective disorder, bipolar type in the medical record, but the MDS assessments were inconsistent: one assessment showed schizophrenia/schizoaffective disorders as not active, while a later assessment marked schizophrenia/schizoaffective disorders as active. The resident’s medication orders included escitalopram for depression, divalproex sodium for bipolar disorder, and risperidone for schizoaffective disorder. Psychiatric progress notes reviewed by the surveyor did not document symptoms supporting schizoaffective disorder. A psychiatric note entered by the CRNP described the resident as stable, with no psychosis, hallucinations, delusions, mood instability, or other abnormal behaviors, yet the diagnosis section still listed schizoaffective disorder, bipolar type. Earlier psychiatric notes did not list schizoaffective disorder as a diagnosis. The surveyor also reviewed the order audit report showing risperidone was entered for schizoaffective disorder, and the DON stated she entered the order based on a verbal order from an NP. During interviews, the DON stated she requested a review of the resident’s risperidone use because she knew psychotropic medications could negatively affect elderly residents and wanted a GDR review. The CRNP stated she added schizoaffective disorder as a differential diagnosis because of behaviors, delusions, irritable mood, and depression, but when asked where the record supported those findings, she could not identify documentation. After reviewing the past two years of records, the CRNP told the surveyor the diagnosis should not have been added and was likely a typographical error.
Delayed Treatment for Stage 3 Pressure Ulcer
Penalty
Summary
Failure to provide necessary treatment and services to promote the healing of a pressure ulcer occurred for Resident #14, who was admitted in August 2025 with an open wound to the sacral area and no measurements documented. A skin/wound note dated 8/11/25 identified the wound as a right buttock/sacrum stage 3 pressure sore, and the resident reported that the wound was present on admission. The admission MDS also documented a stage 3 pressure ulcer that was present on admission. A review of the order summary report showed that no wound treatment was implemented for the resident’s stage 3 pressure ulcer until 8/12/25, 7 days after admission. During interview, the DON confirmed that the resident had a sacral stage 3 wound upon admission, but staff only applied incontinence care cream every shift before wound treatment was started.
Medication Error Rate Exceeded 5% Due to Two Omitted Scheduled Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% after an observation of medication administration for one resident revealed two omissions out of 25 opportunities for error, resulting in an 8% medication error rate. During the observation, a CMA prepared and administered six medications for the resident, including carbidopa/levodopa, metformin, a multivitamin, omeprazole, sertraline, and liothyronine, and stated that synthroid had been given earlier in the day. However, two additional scheduled 9:00 AM medications were not administered during the observed pass: meclizine for vertigo and acetaminophen for wound pain. After the observation, review of the MAR did not show documentation that either of the two 9:00 AM medications had been given by the CMA. When questioned, the CMA stated that acetaminophen had been forgotten because the resident usually refused it due to stomach upset, and then found the meclizine in the medication cart, stating it had been overlooked. Review of the MAR also showed the resident had received the morning acetaminophen dose on 6 of the 7 mornings between 8/13 and 8/19/25.
Failure to Document Pneumonia Vaccine Education and Offer
Penalty
Summary
The facility failed to provide evidence that it educated, offered, or provided the pneumonia vaccine to Resident #9. During record review of immunization records, the surveyor could not find documentation showing that the resident had been offered the vaccine, educated about it, or received it. When the surveyor asked the DON for evidence that the resident had been educated and either received or declined the pneumonia vaccine, the DON was unable to provide any such documentation and stated that offering and educating are part of the admission process and must have been missed.
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What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Westminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carroll Lutheran Village | 0.4 mi | ★★★★★ | 0 | 0 |
| Westminster Rehabilitation And Wellness Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Autumn Lake Healthcare At Long View | 9.1 mi | ★★★★★ | 13 | 0 |
| Lorien Taneytown, Inc | 11.1 mi | ★★★★★ | 33 | 0 |
| Future Care Cherrywood | 11.6 mi | ★★★★★ | 20 | 0 |
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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.