Church Hill Post-Acute and Rehabilitation Center

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure a resident or resident representative consented to the use of psychotropic medications prior to administration of the medication for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on facility policy review, medical record review, transportation calendar review, and interviews, the facility failed to notify a resident representative of appointments outside of the facility for 1 resident (Resident #1) of 3 resident families interviewed for notifications.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's order for the use of a seatbelt, failed to perform an assessment for the use of a seatbelt, and failed to identify medical symptoms that would require the use of a seatbelt for 1 resident (Resident #13) of 1 resident reviewed for physical restraints.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to provide a rationale for the continued use of an as needed (PRN) antianxiety medication beyond 14 days for 1 resident (Resident #19) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to obtain a physician's order and assess a resident's ability to perform tracheostomy (surgical opening into the windpipe) self-care for 1 resident (Resident #2) of 1 resident reviewed for tracheostomy.

Inspectors wroteBased on facility policy review, facility documentation review, and interviews, the facility failed to employ a qualified social worker on a full-time basis. Review of the facility's undated policy titled, Social Services guidelines, revealed .A facility will employ a social worker on a full-time basis . Review of a facility typed document dated 2/12/2026, signed by the Administrator revealed from 5/9/2025 to 5/27/2025, 6/10/2025 to 8/11/2025, 10/8/2025 to 11/26/2025, and from 1/5/2026 to current (2/12/2026) the facility did not employ a qualified social worker for approximately 167 days or 5.5 months out of 9 months reviewed. [...]

Inspectors wroteBased on facility documentation review, medical record review, and interview the facility failed to have the minimum required disciplines attend the Interdisciplinary (IDT) care plan meetings for 1 (Resident #1) of 4 residents reviewed for care plan timing and revision.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to administer a feeding tube formula (liquid nutrition delivered through a tube inserted into the stomach) as ordered by the physician for 1 resident (Resident #1) of 2 residents reviewed for tube feeding nutrition.

Inspectors wroteBased on facility policy review, job description reviews, review of the Centers for Disease (CDC) website for recommendations and guidance for Enhanced Barrier Precautions (EBP) and Coronavirus Disease 2019 (COVID-19), medical record reviews, observations, and interviews, the facility failed to ensure the nursing staff were knowledgeable and fully understood of 6 residents (Residents # 13, #24, #25, #52, #56, and #83) in EBP on 3 of 4 hallways (200, 300, and 400 hallways), of 4 residents (Residents #102, #507, #508, and #509) with active COVID-19 infection on 1 of 4 hallways (100 hallway), and implemented the appropriate use of Personal Protective Equipment (PPE) for isolation rooms to prevent and control the spread of COVID-19, and other infectious organisms. [...]

Inspectors wroteBased on facility policy review, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, job description review, facility assessment review, and interviews, the facility's Administration failed to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The facility's Administration failed to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility's Administration failed to accurately identify residents with an active diagnosis of COVID-19. The facility's Administration failed to ensure the completion of COVID-19 testing of the staff during the COVID-19 outbreaks from 8/2024-11/2024. [...]

Inspectors wroteBased on facility policy review, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidance, job description review, facility assessment review, and interviews, the Governing Body failed to provide oversight to Administration to ensure current CDC guidelines were utilized to prevent and control the spread of COVID-19 to the residents and employees. The Governing Body failed to provide oversight to Administration to ensure the staff were competent and knowledgeable on Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices which included use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The Governing Body failed to provide oversight to Administration to accurately identify residents with an active COVID-19 infection. [...]

Inspectors wroteBased on facility policy review, job description review, facility assessment review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, facility documentation review, medical record review, observations, and interviews, the facility's QAPI program failed to ensure an effective, data-driven QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to infection control practices. The facility ' s QAPI committee failed to develop and implement effective processes or initiate action plans for performance improvement when the committee failed to recognize poor infection control practices of the facility and to ensure an effective infection control program to mitigate the spread of disease. [...]

Inspectors wroteBased on facility policy review, Centers for Disease Control and Prevention (CDC) recommendations and guidance review, medical record review, observations, and interviews, the facility failed to ensure current CDC guidelines dated 6/24/2024 and 10/28/2024 were followed to prevent and control the spread of COVID-19 to residents and staff, failed to identify and track residents with an active COVID-19 infection, failed to wear appropriate Personal Protective Equipment (PPE) in COVID-19 isolation rooms, and failed to perform facility wide employee testing and recommended quarantine time during the COVID-19 outbreaks. The facility failed to ensure COVID-19 positive residents were quarantined according to CDC guidance when Residents #608, #619, and #509 were admitted with COVID-19. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure services were provided to meet professional standards of quality and acceptable standards of clinical practice by not obtaining vital signs per physician orders for residents with an active COVID-19 infection diagnosis for 36 of 40 residents (Resident #96, #45, #31, #33, #11, #609, #64, #93, #15, #510, #612, #611, #80, #506, #613, #615, #54, #68, #27, #53, #12, #95, #74, #3, #30, #37, #617, #34, #618, #72, #103, #507, #102, #508, #619, and #509) reviewed with active COVID-19 infection and 1 of 8 residents (Resident #99) reviewed for medication administration when nursing staff administered oral medication with a 60 milliliter (ml) syringe to Resident #99 who was at high risk for aspiration. [...]

Inspectors wroteBased on facility policy review, observations and interviews, the facility failed to maintain a clean, comfortable, and home like environment for 5 hallways of 5 hallways observed for comfortable and home like environments.

Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to discard expired food in 1 of 1 kitches which had the potential to affect 99 of 99 residents.

Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to develop and implement the base line care plan for active COVID-19 infections for 4 of 6 (Resident #608, #615, #617, and #509) residents admitted with an active COVID-19 infection.

Inspectors wroteBased on facility policy review, Centers for Disease (CDC) recommendations and guidance review, facility documents review, medical record review, and interview, the facility failed to ensure COVID-19 positive residents had care plans timely revised to include COVID-19 isolation requirements and personal protective equipment (PPE) usage by employees, recommended by the CDC, to control the exposure and spread of the COVID-19 virus during the facility's COVID-19 outbreak from 8/9/2024 through 11/16/2024, for 10 residents (Residents #53, #609, #510, #68, #93, #15, #615, #507, #619 and #509) of 40 residents reviewed for care plans. The facility failed to ensure fall interventions were revised on the care plan for 1 resident (Resident #43) of 3 residents reviewed for falls and failed to revise the code status for 1 resident (Resident #95) of 24 residents reviewed for advance directives.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medications were properly stored in 2 medication carts (A-Wing and C-Wing) of 4 medication carts reviewed for medication storage.

Inspectors wroteBased on medical record review, observations, and interview, the facility failed to protect the resident's right to dignity when an indwelling catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #90) of 99 residents observed for dignity.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the residents' protected health information remained private and confidential on 2 (D-Wing and C-Wing) of 4 hallways, which had the potential to allow unauthorized individuals access to the residents' private health information.

Inspectors wroteBased on facility policy review, medical record review, observations and interviews, the facility failed to develop a person-centered comprehensive care plan related to a stomach drain for 1 resident (Resident #36) and for a COVID-19 infection for 1 resident (Resident #506); the facility failed to implement care plan interventions related to sexual behaviors for 1 resident (Resident #606), and related to meal assistance for 1 resident (Resident #93) of 40 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to administer a feeding tube formula (liquid nutrition delivered through a tube inserted into the stomach) as ordered by the physician for 1 resident (Resident #1) of 2 residents reviewed for tube feeding nutrition.

Inspectors wroteBased on facility policy review, observations and interviews, the facility failed to maintain and store oxygen equipment in a clean and sanitary condition for 2 residents (Resident #39 and Resident #59) of 8 residents reviewed for oxygen equipment storage.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure a physician order for bed rail usage was obtained prior to use for 1 resident (Resident #99) of 3 residents reviewed for bed rails.

Inspectors wroteBased on facility policy review, facility documents, medical record review and interviews, the facility failed to maintain complete records of pharmacy reviews and a record of the provider's responses to irregularities identified by the pharmacist for 2 residents (Resident #37 and Resident #71) of 5 residents reviewed for pharmacy services.

Inspectors wroteBased on facility documentation review, medical record review, and interview, the facility failed to complete the facility assessment to accurately reflect the needs and services provided by the facility, which had the potential to affect 2 of 99 residents (Residents #52 and #86).

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a COVID-19 test result was accurately documented for 5 residents (Resident #37, #45, #33, #80, and #94) of 40 residents reviewed for COVID-19 testing documentation. The facility failed to ensure an order for a urinalysis was obtained timely for 1 resident (Resident #30) of 3 resident reviewed for laboratory services. The facility failed to transcribe a physician's order accurately and timely for 1 resident (Resident #79) of 5 residents reviewed for medication administration.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview the facility failed to ensure an allegation of abuse was reported to the State Survey agency for 1 resident (Resident #1) of 6 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to prevent and protect 2 residents (Resident #65 and #45) from abuse of 16 residents reviewed for abuse. The facility's failure to ensure interventions were implemented to prevent continued wandering of Resident #30 in and out of other residents' rooms and the failure of a Certified Nursing Assistant (CNA) to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, with Resident #30 hitting Resident #65 in the head, resulted in psychosocial harm to Resident #65. Resident #30 continued to wander throughout the facility, in and out of other residents' rooms, then entered Resident #45's room, attempted to choke her, and stated she would kill her. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to timely report to the State Survey Agency an allegation of abuse for 2 residents (Residents #65 and #45) and failed to timely report an allegation of abuse to Administration for 1 resident (Resident #45) of 16 residents reviewed for abuse. Resident #30 hit Resident #65 in the head. Resident #30 continued to display wandering and aggressive behavior and entered Resident #45's room and attempted to choke Resident #45. The facility's failure to ensure allegations of abuse were reported timely placed all residents in the facility in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 2 residents (Resident #30 and #65) of 16 residents reviewed for abuse when a Certified Nursing Assistant (CNA) failed to separate Resident #30 and Resident #65 when she overheard them arguing in the hallway, which resulted in a resident to resident altercation when Resident #30 hit Resident #65 in the head. This resulted in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room and attempting to choke Resident #45 and stating she would kill Resident #45. [...]

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure staff had the knowledge and skill set required to develop appropriate behavior health care plans and provide care to meet the behavioral health needs of 2 residents (#30 and #65) of 4 residents reviewed for behaviors. The facility's failure to have competent staff to implement appropriate behavioral interventions resulted in an altercation between Resident #30 and Resident #65 where Resident #65 suffered psychosocial harm. Resident #30's continued wandering behavior led to Resident #30 wandering into Resident #45's room and placing her hands-on Resident #45's neck and attempting to choke her. [...]

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement individualized care plan interventions to include and support each resident's Dementia care needs for 5 residents (Residents #30, #65, #41, #43, and #46) of 7 residents reviewed for Dementia care. The facility's failure to develop, implement and maintain individualized care plans for Dementia care needs resulted in a resident to resident altercation between Resident #30 and Resident #65 with Resident #30 hitting Resident #65 in the head resulting in psychosocial harm for Resident #65. Resident #30's continued wandering led to Resident #30 entering Resident #45's room, attempting to choke her, and stating she would kill her. [...]

Inspectors wroteBased on review of facility policy, medical record review, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the root causes of a resident to resident altercation when Resident #30 hit Resident #65 in the head, which led to psychosocial harm to Resident #65. The facility's failure to investigate an instance of resident to resident abuse and to implement individualized, person-centered behavior interventions for Resident #30's continued wandering throughout the facility resulted in Resident #30 later entering Resident #45's room and placing her hands on the resident's neck and attempting to choke Resident #45. [...]