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Deficiency Records for Church Hill Post-Acute and Rehabilitation Center

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.

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 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-07-13 2021-07-19 N
Respond appropriately to all alleged violations. Health 2021-07-13 2021-07-19 N
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 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2021-07-13 2021-07-19 N
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 N
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

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