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Deficiency Records for Church Hill Post-Acute and Rehabilitation Center
View the most recent health deficiencies and inspection results for Church Hill Post-Acute and Rehabilitation Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Church Hill Post-Acute and Rehabilitation Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2026-02-12 | 2026-03-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-05-05 | 2025-05-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-01-23 | 2025-02-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-11-18 | 2025-02-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-18 | 2024-12-16 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2024-11-18 | 2024-12-16 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-11-18 | 2024-12-16 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-11-18 | 2024-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-18 | 2024-12-16 | 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 | 2024-11-18 | 2024-12-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-11-18 | 2024-12-16 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-11-18 | 2024-12-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-11-18 | 2024-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-11-18 | 2024-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-18 | 2024-12-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-11-18 | 2024-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-18 | 2024-12-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-11-18 | 2024-12-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-11-18 | 2024-12-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-11-18 | 2024-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-18 | 2024-12-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-11-18 | 2024-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-11-18 | 2024-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-11-18 | 2024-11-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-11-18 | 2024-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-05 | 2024-09-20 | 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 | 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 |
| 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 |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-17 | 2019-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-17 | 2019-05-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-17 | 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 | 2019-04-17 | 2019-04-23 | N |