Deficiency Records for Church Hill Post-Acute and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Church Hill Post-Acute and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-01 | 2023-03-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-13 | 2022-10-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-13 | 2021-07-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-13 | 2021-07-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-13 | 2021-07-19 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-07-13 | 2021-07-19 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-13 | 2021-07-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-13 | 2021-07-19 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-15 | 2019-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-15 | 2019-05-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-15 | 2019-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-17 | 2019-05-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-17 | 2019-05-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-17 | 2019-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-17 | 2019-05-09 | N |
| Ensure 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. | Health | 2019-04-17 | 2019-05-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-15 | 2019-04-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-18 | 2018-05-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-04-18 | 2018-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-18 | 2018-05-18 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-04-18 | 2018-05-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-04-18 | 2018-05-18 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-04-18 | 2018-05-18 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-04-17 | 2018-05-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-17 | 2018-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-17 | 2018-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-17 | 2018-04-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-04-17 | 2018-04-17 | N |
