Atlee Hill Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Atlee Hill Health and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF760Dec 21, 2023

  Based on record reviews and interviews, it was determined that the facility failed to ensure residents did not receive medications ordered for another resident. This deficient practice resulted in actual harm to Resident #5 who experienced critically low heart rate and blood pressure and required hospitalization . This was evident for 1 (Resident #5) resident out of 39 residents reviewed during the annual survey. The findings include: On 12/13/23 surveyor review of Resident #5's record revealed a Health Status Note dated 1/11/23. The note stated: Resident #5 was given another Resident's medication in error. Vital Sign assessment done every hour to monitor blood pressure (B/P) and pulse. […]

• No harm, potential for more than minimal, widespreadF607Aug 29, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2025

  Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents.The findings include:1) An initial tour of the facility's kitchen with Staff #23, the dietary director, on 8/19/2025 at 7:30 AM revealed the following in the walk-in refrigerator and walk-in freezer:-Leftover Roast Beef with a date prepared as 3/18/25 and a use-by date of 3/21/25. Staff said that it should have been discarded a long time ago. Staff took it to discard it. - Leftover Tortellini pasta salad with a date prepared as 8/13/25 and had no use-by date. Staff stated it should have been discarded a day prior.-Roasted Turkey with a date prepared as 8/6/25 had no use-by date. […]

• No harm, potential for more than minimal, widespreadF880Aug 29, 2025

  Based on interviews, record reviews and observations, it was determined that the facility failed to 1) have a water management system in place to identify Legionella and other harmful waterborne germs in the building and 2) ensure that wall-mounted Hand sanitizing dispensers in resident and staff areas were maintained within their expiration dates. This was evident during the recertification survey.The findings include: Legionella is a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease in people at higher risk, such as those over fifty years old, people with chronic lung disease, or those with weakened immune systems. […]

• No harm, potential for more than minimal, widespreadF812Dec 21, 2023

  Based on observation and interview with staff, it was determined that the facility failed to store food and equipment in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: On [DATE] at 8:10A.M., during the initial tour of the kitchen, Surveyors inspected a small walk-in refrigerator/freezer. Surveyors observed a 2lb (pound) bag of green sweet peas opened and undated, a 2lb bag of broccoli florets opened, undated, and wrapped in plastic wrap, and potato wedges opened, undated, and wrapped in plastic wrap. During the continued tour of the kitchen, Surveyors inspected the main walk-in refrigerator. […]