Facility profile · CCN 445237
Church Hill Post-acute And Rehabilitation Center
34 federal citations on record , including 12 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $250,780.
Record summary
Federal record · Q1 202634
Total citations
23
Last 3 years
12
Actual harm+
2
Federal penalties
$250,780
Total fines
—
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
34 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| May 5, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Complaint |
| Jan 23, 2025 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint |
| Nov 18, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint |
| Nov 18, 2024 | F880 | Provide and implement an infection prevention and control program. | L | Standard |
| Nov 18, 2024 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | L | Standard |
| Nov 18, 2024 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Nov 18, 2024 | F838 | 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. | D | Standard |
| Nov 18, 2024 | F837 | 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. | L | Standard |
| Nov 18, 2024 | F835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | L | Standard |
| Nov 18, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Nov 18, 2024 | F761 | 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. | E | Standard |
| Nov 18, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Nov 18, 2024 | F726 | 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. | L | Standard |
| Nov 18, 2024 | F700 | 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. | D | Standard |
| Nov 18, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Nov 18, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K | Standard |
| Nov 18, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Nov 18, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Nov 18, 2024 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | Standard |
| Nov 18, 2024 | F584 | 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. | F | Standard |
| Nov 18, 2024 | F583 | Keep residents' personal and medical records private and confidential. | D | Standard |
| Nov 18, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Sep 5, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Jul 13, 2021 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | L | Standard |
| Jul 13, 2021 | F744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | L | Standard |
| Jul 13, 2021 | F741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | L | Standard |
| Jul 13, 2021 | F610 | Respond appropriately to all alleged violations. | L | Standard |
| Jul 13, 2021 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | L | Standard |
| Jul 13, 2021 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | L | Standard |
| Apr 17, 2019 | F761 | 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. | D | Standard |
| Apr 17, 2019 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Apr 17, 2019 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Apr 17, 2019 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Apr 17, 2019 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 1 civil money penalties totaling $250,780 and 1 payment-denial actions spanning 72 days.
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Nov 18, 2024 | Fine | $250,780 | — |
| Nov 18, 2024 | Payment Denial | — | Nov 28, 2024 · 72 days |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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