Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Church Hill Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not comply with its own policy requiring a full-time social worker and went extended periods without a qualified social worker on staff. Over multiple months within a 9‑month review period, no qualified social worker was employed, and an unqualified staff member who originally worked as a concierge was informally assigned to handle social work responsibilities despite lacking a social work degree or training. The Administrator confirmed these gaps in qualified social work coverage.
A resident with dementia, psychosis, depression, and anxiety disorder was given psychotropic medications, including clonazepam and risperidone, before consent was obtained from the resident’s representative. The DON confirmed that consent was supposed to be discussed and obtained prior to starting new medications, but the consent form was not signed until after the meds had already been initiated.
Failure to notify a resident’s RP of outpatient appointments. A resident with dementia, CVA, hemiplegia, and cognitive impairment was transported by the facility for orthopedic knee injection visits, but the transportation tech did not notify the RP of the type, location, date, or time of the appointments on two occasions. The RP stated the resident went for knee shots without notice, and the VP for Clinical Services confirmed notification was expected.
Failure to Obtain Order and Restraint Assessment for Wheelchair Seatbelt: A resident with cerebral palsy, Lennox-Gastaut syndrome, seizures, and very poor trunk control was observed in a positioning wheelchair with a seatbelt across the waist. Staff and the responsible party stated the seatbelt was used for safety during seizures and that the resident could not release it independently, yet the record had no physician order or restraint assessment, and the MDS coded restraints as not used. An LPN said the seatbelt was not considered a restraint, while the MDS Coordinator and DON later confirmed it met the definition of a restraint.
A resident with dementia, psychosis, depression, and anxiety received a PRN clonazepam order that was entered for 60 days even though the psych eval recommended 14 days. The MAR reflected the longer PRN order, and the record contained no documented rationale for extending the PRN psychotropic beyond 14 days, which the VP of Clinical Services and DON acknowledged was required.
A resident with COPD and a tracheostomy was observed receiving trach care in the facility, but the chart lacked a physician order for self-care and had no documented assessment of the resident’s ability to change the inner cannula or perform trach care using sterile technique. An LPN and the resident stated he did his own trach care, another LPN agreed, and the DON confirmed the missing order and assessment; the physician said nursing was told to monitor the care and did not know an order had been written for self-care.
A resident with multiple complex medical conditions did not have the required interdisciplinary team (IDT) members, such as a nurse or physician, present at care plan meetings. Documentation and staff interviews confirmed that only the Social Services Director, Dietary Manager, and the resident or representative attended, contrary to facility policy requiring broader IDT participation.
A resident with multiple health conditions was mistakenly given the wrong tube feeding formula, Osmolite 1.2 CAL, instead of the prescribed Glucerna 1.5 CAL. The error was discovered by an LPN the next morning, and the correct formula was administered immediately. The resident showed no signs of distress, and the incident was reported to the DON and Medical Director.
The facility failed to ensure staff understood Enhanced Barrier Precautions (EBP) and PPE use, affecting residents with COVID-19 and other infections. Observations showed staff entering rooms without proper PPE or hand hygiene. Interviews revealed a lack of training and understanding of EBP, with outdated policies contributing to the issue.
The facility failed to follow CDC guidelines for COVID-19 prevention and control, leading to two outbreaks affecting residents and staff. The administration did not ensure staff competency in Enhanced Barrier Precautions and PPE usage, allowed COVID-19 positive employees to work with non-positive residents, and failed to quarantine individuals as required. The QAPI program did not address these deficiencies, and the Medical Director's concerns about infection control practices were not implemented.
The facility's Governing Body failed to ensure compliance with CDC guidelines for COVID-19 prevention, leading to inadequate staff competency in infection control practices and improper use of PPE. The facility experienced two COVID-19 outbreaks, with positive employees returning to work prematurely, increasing infection risk. The QAPI program was ineffective in addressing these issues, and discrepancies in meeting records raised concerns about oversight. Interviews revealed poor communication between the Administrator and the Governing Body, with no formal reporting process in place.
The facility's QAPI program failed to address infection control deficiencies, allowing COVID-19 positive employees to work and exposing residents to infection. Two outbreaks occurred, with 28 residents and 15 employees testing positive initially, and 10 residents and 5 employees in a subsequent outbreak. The facility did not follow CDC guidelines for isolation, failed to ensure competent staff, and did not comply with physician's orders, resulting in Immediate Jeopardy for all residents.
The facility failed to follow CDC guidelines for COVID-19 management, resulting in two outbreaks affecting residents and staff. The facility did not properly identify and track infections, enforce PPE use, or conduct necessary testing and quarantine measures. This led to an Immediate Jeopardy situation, indicating a serious risk of harm.
The facility failed to monitor vital signs every four hours for residents with active COVID-19 infections, as per physician orders, and improperly administered medication to a resident at high risk for aspiration. These deficiencies led to an Immediate Jeopardy situation, indicating a potential for serious harm to residents.
The facility failed to maintain a clean and homelike environment, with observations revealing stained carpets and disrepair in resident rooms, including broken furniture and exposed drywall. Staff confirmed awareness of these issues, which had been pending repair since 2022.
The facility failed to discard expired food items in the kitchen, affecting all 99 residents. An observation revealed expired grits, bologna, and allspice available for use, along with improperly sealed black pepper. The CDM confirmed these items were expired and not discarded.
The facility failed to develop and implement baseline care plans for residents admitted with active COVID-19 infections, as required by their policy. Despite physician orders for isolation precautions and regular monitoring, the care plans did not reflect these needs, leaving staff unaware of necessary PPE requirements. This oversight was confirmed by the MDS/Care Plan Coordinator, highlighting a significant lapse in policy adherence.
The facility failed to timely revise care plans for residents with COVID-19, falls, and code status changes. Care plans for ten residents were not updated to include COVID-19 isolation requirements, and a resident's fall risk was not addressed with new interventions. Additionally, a resident's code status change to DNR was not reflected in their care plan.
The facility failed to properly store medications in two medication carts. A resident's Lorazepam liquid was stored at room temperature instead of refrigerated, risking reduced effectiveness. Additionally, two house stock medications for constipation were found opened and undated. The facility's policy requires proper storage conditions, including refrigeration for certain medications.
A resident with multiple health conditions was mistakenly given the wrong tube feeding formula for about 10 hours. The error was discovered by an LPN, and the correct formula was administered immediately. The resident showed no signs of distress, and the incident was reported to the DON and Medical Director.
A resident with moderate cognitive impairment and an indwelling urinary catheter had their drainage bag left uncovered and visible to the public, contrary to their care plan. This oversight was confirmed by a registered nurse, highlighting a failure to maintain the resident's dignity.
The facility failed to protect residents' health information on D-Wing and C-Wing. On D-Wing, an RN left a computer screen unlocked on a medication cart, exposing residents' health information. On C-Wing, an LPN left a resident roster with sensitive information visible on a medication cart. Both staff members confirmed the lapses in maintaining confidentiality.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident with a gallbladder drain did not have this included in their care plan, while another resident with COVID-19 lacked related interventions. Additionally, a resident requiring one-on-one supervision for sexual behaviors was left unsupervised, and a resident needing meal assistance did not receive it. These oversights were confirmed by staff and care plan reviews.
The facility failed to maintain and store oxygen equipment in a clean and sanitary condition for two residents. A resident with Dementia and other conditions had a nebulizer mask uncovered on the nightstand, confirmed by an LPN. Another resident with COPD and other diagnoses had multiple nebulizer masks, some out of date and one with a cloudy substance, not stored properly. An LPN confirmed the unsanitary conditions and was unsure about the cleaning schedule.
A facility failed to obtain a physician's order for bed rail use for a resident with conditions including Epilepsy and Cerebral Palsy. The resident's care plan included padded bed rails for protection, but observations and staff interviews confirmed the rails were in use before obtaining the necessary order, contrary to facility policy.
The facility failed to maintain complete records of pharmacy reviews and provider responses for two residents. A resident with multiple diagnoses, including Rheumatoid Arthritis and Depression, had medication irregularities noted by the pharmacist, but the medical record lacked documentation of these irregularities and provider responses. Another resident with Delusional Disorder and Dementia also had similar issues. Staff confirmed the absence of necessary documentation, indicating a lapse in maintaining accurate medication records.
The facility's assessment failed to accurately reflect the needs of two residents, one identifying as transgender and another with a language barrier, as it did not account for their specific cultural and communication preferences.
The facility failed to document COVID-19 test results accurately for several residents, leading to inconsistencies in medical records. Additionally, a urinalysis was not obtained timely for a resident with altered mental status, and a transcription error resulted in a medication administration record not reflecting the correct dosage for over a year. These deficiencies highlight lapses in documentation and communication within the facility.
A facility failed to report an alleged abuse incident to the State Survey agency as required by policy. An EMT reported potential sexual abuse of a resident, but the facility's investigation found no evidence, deeming it malicious gossip. The resident, who was cognitively intact, had been evaluated in the ER for self-harm thoughts. The facility did not report the allegation, leading to a deficiency.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker as required by its own policy and federal regulations for a facility with more than 120 beds. The facility’s undated Social Services guidelines stated that a social worker would be employed on a full-time basis, yet a facility document signed by the Administrator on 2/12/2026 showed that 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 2/12/2026, the facility did not employ a qualified social worker, totaling approximately 167 days (5.5 months) out of 9 months reviewed. During an interview, the individual currently functioning in the social worker role stated they began employment in October as a concierge and served in that role until early January, after which they were acting as the social worker despite having no social work degree or training and only “helping out with the social worker stuff” until a social worker could be hired. In a separate interview, the Administrator confirmed the periods during which the facility did not have a qualified social worker employed.
Psychotropic Medications Started Before Consent Was Obtained
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative consented to psychotropic medication use before the medications were administered to Resident #19. The resident was admitted with diagnoses including dementia, psychosis, depression, and anxiety disorder, and a quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Facility policy stated that residents and/or representatives were to be educated on the risks and benefits of psychotropic drug use and alternative treatments/non-pharmacological interventions. The medical record showed Resident #19 received Clonazepam 0.5 mg three times daily starting on 1/13/2026 for anxiety disorder and Risperidone 0.25 mg three times daily starting on 1/27/2026 for unspecified psychosis, with a later order increasing Risperidone to 0.5 mg three times daily on 2/4/2026. A psychotropic medication consent form was not obtained until 2/11/2026, after the medications had already been started. During interview, the DON stated that new medications and treatments were to be discussed with the resident or resident representative and consent obtained prior to initiation, and confirmed that consent for Resident #19 was not obtained before the medications were started.
Failure to Notify Family of Outpatient Appointments
Penalty
Summary
The facility failed to notify a resident representative of outpatient appointments for one resident who had dementia, a prior cerebral infarction, and hemiplegia. The resident’s record showed cognitive impairment on MDS assessments, with a BIMS score indicating moderate impairment on one assessment and severe impairment on a later assessment, and the resident required assistance with transfers and standing. The facility policy stated that residents needing an escort to appointments due to cognitive or physical limitations should have arrangements made ahead of time and that the family would be notified of the appointment. Review of the transportation calendar showed the resident was transported to orthopedic outpatient appointments for knee injections on two occasions. An appointment communication form documented steroid injections and a follow-up appointment, and an FNP note later stated the resident had recently followed outpatient with orthopedics and received steroid injections into the knees. During interview, the resident’s responsible party stated the facility transported the resident for knee shots without notifying the responsible party and said this happened twice. The transportation technician confirmed transporting the resident to both orthopedic appointments and confirmed the responsible party was not notified, and the VP for Clinical Services stated the technician was expected to notify the responsible party of the appointment details.
Failure to Obtain Order and Restraint Assessment for Wheelchair Seatbelt
Penalty
Summary
The facility failed to obtain a physician's order for the use of a seatbelt, failed to complete a restraint assessment, and failed to identify the medical symptoms that would justify the use of the seatbelt for one resident. The facility policy stated restraint use is limited to circumstances in which the resident has medical symptoms that warrant the restraint, that a physician's order alone is not sufficient, and that the facility must determine the specific symptom, how the restraint treats it, and the anticipated duration and release schedule. The resident's record showed diagnoses including spastic quadriplegic cerebral palsy, Lennox-Gastaut syndrome, epilepsy, adult failure to thrive, and gastrostomy status, with care plans noting poor trunk control, involuntary and uncoordinated movements, seizures, nonverbal status, inability to follow directions, and dependence on staff for all ADLs. The medical record also showed a physician order for enhanced 1:1 supervision for safety, and a later care plan entry stating a seat belt/harness was used in the wheelchair due to very poor trunk control. However, the MDS assessment stated physical restraints were not used, and the record contained no physician's order for the seatbelt and no documentation that a restraint assessment had been completed. During observation, the resident was seated in a positioning wheelchair with a seatbelt across the waist while visiting with family, and the responsible party stated the seatbelt was used for safety to keep the resident in the chair during seizures and that the resident could not release it on his own. Staff interviews confirmed the seatbelt was used when the resident was up in the wheelchair because of seizures and poor trunk control, and that the resident was unable to remove it independently. An LPN stated the seatbelt was not considered a restraint and said there was no awareness of any restraint assessment. The MDS Coordinator later confirmed the seatbelt met the definition of a restraint and stated there was no order for it. The DON stated the resident had been using the seatbelt since admission and at home before admission, confirmed it met the definition of a restraint because the resident could not remove it on his own, and acknowledged that an order should have been obtained before the seatbelt was initiated and that a restraint assessment should have been performed.
Missing Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a documented rationale for continuing a PRN psychotropic medication beyond the 14-day limit for Resident #19. The resident was admitted with diagnoses including unspecified dementia, unspecified psychosis, depression, and anxiety, had a BIMS score of 10 indicating moderate cognitive impairment, and had an active diagnosis of anxiety disorder with antianxiety medication use. A comprehensive care plan identified potential mood state issues related to anxiety and directed medication administration as ordered. A psychiatric periodic evaluation documented anxiety and noted that clonazepam 0.5 mg PRN for anxiety was recommended for 14 days, but the provider entered a physician order for clonazepam 0.5 mg by mouth as needed for anxiety for 60 days. The MAR reflected the 60-day PRN order, and a later psychiatric periodic evaluation continued to list clonazepam 0.5 mg TID and qd PRN anxiety. Review of the record found no rationale documented for extending the PRN clonazepam beyond 14 days. During interviews, the VP of Clinical Services and the DON acknowledged that PRN psychotropic medications were to be limited to 14 days and that a rationale was required to extend them beyond that period.
Failure to Order and Assess Tracheostomy Self-Care
Penalty
Summary
The facility failed to obtain a physician order and failed to assess a resident’s ability to perform tracheostomy self-care for one resident with diagnoses including chronic obstructive pulmonary disease and tracheostomy. The resident was admitted alert and oriented to person, place, time, and situation, and the medical record showed a physician order for tracheostomy care, including changing the inner cannula daily and as needed and trach care every 12 hours and as needed using sterile technique. However, there was no order for the resident to perform his own tracheostomy care and no documentation that he had been assessed for his ability to change the inner cannula or complete his own tracheostomy care. During observation, the resident had a tracheostomy. An LPN stated the resident performed his own tracheostomy care but had not been observed doing so. The resident stated he changed his own inner cannula and provided his own tracheostomy care while in the facility. Another LPN also stated the resident performed his own tracheostomy care. The DON confirmed there was no order for the resident to perform his own tracheostomy care and that the resident had not been assessed to ensure he could perform tracheostomy care appropriately using sterile technique. The physician stated nursing was told to monitor that the care was being done properly and said he did not know that he had written an order for the resident to do his own trach care. The DON later confirmed the order for the resident to perform his own tracheostomy care was not added until 8 days after admission and 2 days after the survey investigation began.
Failure to Ensure Required IDT Attendance at Care Plan Meetings
Penalty
Summary
The facility failed to ensure that the minimum required interdisciplinary team (IDT) members attended care plan meetings for a resident who was admitted and later readmitted with multiple complex diagnoses, including hepatic encephalopathy, alcoholic cirrhosis with ascites, dependence on renal dialysis, and esophageal varices. According to facility policy, the IDT for care planning should include, at a minimum, the attending physician, a registered nurse, a nursing assistant, a member of food and nutrition services, the resident or their representative, and other appropriate staff. However, documentation for three separate care plan meetings showed that only the Social Services Director, the Dietary Manager, and the resident or their representative were present, with no nurse, physician, or other required disciplines in attendance. Interviews with the Director of Nursing and the Social Services Director confirmed that the full IDT was not present at these meetings. The Social Services Director stated that only she and the Dietary Manager attended the meetings, and that other required staff were not present due to being occupied with other duties. This failure to include the required disciplines in the care plan meetings was identified through facility documentation review, medical record review, and staff interviews.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility failed to administer the correct tube feeding formula as ordered by the physician for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had a history of stroke, epilepsy, type 2 diabetes, gastrointestinal bleed, dysphagia, and aphasia, was supposed to receive Glucerna 1.5 at 70 milliliters per hour. However, on January 1, 2025, the resident was mistakenly given Osmolite 1.2 CAL instead of the prescribed Glucerna 1.5 CAL. This error was discovered by an LPN the following morning, and the correct formula was administered immediately thereafter. The incident was reported to the Director of Nursing and the Medical Director, who confirmed that the resident did not exhibit any signs of distress or discomfort following the administration of the incorrect formula. The facility's policy on feeding tube guidelines emphasizes the importance of administering enteral nutrition as per the practitioner's orders, which was not adhered to in this case. The Executive Director of Nursing expressed that it was expected for nurses to follow the physician's orders accurately.
Deficiency in Infection Control and PPE Usage
Penalty
Summary
The facility failed to ensure that nursing staff were knowledgeable and fully understood Enhanced Barrier Precautions (EBP) and the appropriate use of Personal Protective Equipment (PPE) for residents with active COVID-19 infections and other infectious organisms. This deficiency was observed across multiple hallways, affecting several residents who required EBP for various conditions, including wounds, ESBL infections, and indwelling urinary devices. The facility's non-compliance placed residents in Immediate Jeopardy, as staff did not adhere to infection control practices, such as wearing gowns and gloves during high-contact activities and performing hand hygiene. Observations revealed that staff, including Patient Care Assistants (PCAs) and Certified Nursing Assistants (CNAs), frequently entered and exited rooms without performing hand hygiene or wearing the required PPE. For instance, a PCA was observed delivering meal trays to multiple residents in EBP rooms without washing hands or wearing gowns and gloves. Similarly, a Paid Feeding Assistant (PFA) entered a droplet isolation room without the appropriate PPE, and a Risk Manager entered a COVID-19 positive resident's room without donning PPE, later accessing clean supplies and re-entering the room. Interviews with staff indicated a lack of understanding and training regarding EBP and PPE requirements. Some staff believed EBP signage was only for CNAs or associated it with the need for barrier cream, rather than infection control measures. The Infection Preventionist (IP) and Assistant Director of Nursing (ADON) acknowledged deficiencies in staff education and infection control practices, with outdated policies and a lack of awareness of current CDC guidelines contributing to the issue. The facility's administration recognized the need for improvement in infection prevention and control practices, as well as competent staffing.
Failure to Adhere to CDC Guidelines and Infection Control Practices
Penalty
Summary
The facility's administration failed to adhere to current CDC guidelines for preventing and controlling the spread of COVID-19 among residents and staff. This included a lack of competency and knowledge among staff regarding Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices, such as the use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The administration also failed to accurately identify residents with an active COVID-19 diagnosis and did not complete COVID-19 testing for staff during outbreaks from August to November 2024. Additionally, COVID-19 positive employees were allowed to provide care for COVID-19 negative residents, and the facility did not quarantine COVID-19 positive individuals for the required time frame as recommended by the CDC. The facility experienced two COVID-19 outbreaks, with the first occurring from August 9, 2024, to October 11, 2024, affecting 28 residents and 15 employees. The second outbreak began on October 19, 2024, and continued, affecting 10 residents and 5 employees. During these outbreaks, the facility allowed 17 out of 20 COVID-19 positive employees to return to work before completing the required isolation period, increasing the risk of spreading the infection. The facility also failed to ensure that nursing staff were knowledgeable about identifying residents on EBP and active COVID-19 residents, and did not implement appropriate PPE usage for isolation rooms. The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address infection control deficiencies, including the unsafe practice of allowing COVID-19 positive employees to care for non-COVID-19 positive residents. The QAPI committee and the Governing Body did not recognize the need to address staff competency related to infection control practices, nor did they implement corrective actions for deficiencies in physician order compliance related to vital sign monitoring and medication administration. The Medical Director expressed concerns about inconsistent PPE usage and infection control practices, which were not addressed by the facility administration.
Inadequate Oversight and Infection Control Failures
Penalty
Summary
The Governing Body of the facility failed to provide adequate oversight to ensure compliance with CDC guidelines for preventing and controlling the spread of COVID-19. This included a lack of oversight in ensuring staff competency in Enhanced Barrier Precautions (EBP) and COVID-19 isolation practices, as well as the use of appropriate Personal Protective Equipment (PPE) for potentially contagious residents. The facility also failed to accurately identify residents with active COVID-19 infections and did not complete COVID-19 testing for staff according to CDC guidelines during outbreaks. Furthermore, COVID-19 positive employees were allowed to provide care to COVID-19 negative residents, increasing the risk of infection spread. The facility's Quality Assurance and Performance Improvement (QAPI) program was ineffective in identifying and addressing systemic failures related to infection control. The QAPI committee and the Governing Body did not recognize the need to address staff competency in infection control practices, nor did they implement corrective actions for deficiencies in following physician orders for vital sign monitoring and medication administration. The facility experienced two COVID-19 outbreaks, with numerous residents and employees testing positive, yet failed to implement effective measures to control the spread of the virus. Interviews with facility staff revealed a lack of communication and formal reporting between the Administrator and the Governing Body. The Administrator was unable to identify Governing Body members and admitted that there was no formal process for reporting facility issues to them. Additionally, discrepancies were found in the QAPI meeting signature logs, with signatures being added after the fact, raising concerns about the accuracy of attendance records. The Governing Body members could not recall specific discussions or actions taken to address COVID-19 infection control issues, indicating a lack of engagement and oversight in critical areas of facility management.
Inadequate Infection Control and QAPI Program Leads to Immediate Jeopardy
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to effectively identify and address quality deficiencies, particularly in infection control practices. The QAPI committee did not develop or implement effective processes or action plans for performance improvement, failing to recognize poor infection control practices and ensure an effective infection control program. This oversight allowed COVID-19 positive employees to work and provide care for vulnerable and COVID-19 negative residents, exposing them to the infection. The facility census was 99, and the failure to implement proper infection control practices resulted in an Immediate Jeopardy situation, impacting all residents. The facility experienced two COVID-19 outbreaks, with 28 residents and 15 employees testing positive during the first outbreak and 10 residents and 5 employees during the second. The facility allowed 17 of the 20 COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance, increasing the likelihood of spreading the infection. Additionally, the facility failed to accurately identify COVID-19 positive residents and those requiring Enhanced Barrier Precautions (EBP), with employees being non-compliant with PPE usage in EBP rooms for 6 of 26 residents. The facility administration failed to ensure competent nursing staff who understood isolation guidelines and implemented appropriate PPE usage. The administration also failed to ensure compliance with physician's orders and professional standards of care, resulting in substandard quality of care. The Governing Body did not provide adequate oversight to address non-compliance related to infection control, isolation guidelines, and PPE usage. Despite the Medical Director voicing concerns about infection control practices, the facility did not implement his recommendations, contributing to the deficiencies.
Failure to Follow CDC Guidelines for COVID-19 Management
Penalty
Summary
The facility failed to adhere to current CDC guidelines for infection prevention and control, specifically in managing COVID-19 outbreaks. The facility did not properly identify and track residents and staff with active COVID-19 infections during two separate outbreaks. This failure resulted in the spread of COVID-19 among 28 residents and 15 employees during the first outbreak, and 10 residents and 5 employees during the second outbreak. The facility also did not ensure that COVID-19 positive residents were quarantined according to CDC guidance, as evidenced by the cases of several residents who were admitted with COVID-19 but not isolated for the recommended duration. Additionally, the facility did not enforce the use of appropriate Personal Protective Equipment (PPE) in COVID-19 isolation rooms. Staff members were observed not wearing the necessary PPE, such as N95 respirators, gowns, gloves, and eye protection, when entering rooms of residents with confirmed COVID-19 infections. This noncompliance with PPE protocols was noted for multiple residents who were supposed to be under Enhanced Barrier Precautions. The facility also failed to conduct facility-wide employee testing and did not adhere to recommended quarantine times during the COVID-19 outbreaks. Several employees who tested positive for COVID-19 were not excluded from work for the required isolation period, increasing the risk of further transmission within the facility. These deficiencies led to an Immediate Jeopardy situation, indicating a serious risk of harm to residents.
Failure to Monitor Vital Signs and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for monitoring vital signs in residents diagnosed with active COVID-19 infections. This deficiency was identified in 36 out of 40 residents reviewed, where vital signs were not obtained every four hours as ordered. The lapses in monitoring were documented over several days, with some residents not having any vital signs recorded on certain days. This failure to monitor vital signs as per physician orders was a significant deviation from professional standards of care. In addition to the failure in monitoring vital signs, the facility also failed in the administration of medication to a resident at high risk for aspiration. Nursing staff administered oral medication using a 60 ml syringe, which was not within the professional scope of practice for medication administration for this resident. This action posed a significant risk to the resident's health and safety. The deficiencies in monitoring vital signs and medication administration led to an Immediate Jeopardy situation, indicating that the facility's noncompliance had the potential to cause serious harm to residents. The Immediate Jeopardy was identified for multiple federal tags, including F-684, F-726, F-835, F-837, F-867, and F-880, highlighting the substandard quality of care provided by the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all five hallways observed. Observations revealed multiple large stains of various shades, including brown and bright red, on the carpets of the 100, 200, and 300 hallways. Additionally, several resident rooms were found in disrepair, with issues such as broken furniture, missing trim, exposed drywall, and stained walls and curtains. One room had a broken footboard and an adhesive ribbon hanging from the ceiling with small black bugs attached. Another room had a sink with running water despite the faucet handles being in the shut-off position. Interviews with facility staff, including the Administrator and the VP of Life Safety and Environmental Compliance, confirmed awareness of the environmental issues. The Administrator acknowledged that the facility had been aware of the need for repairs since September 2022 but did not begin addressing these issues until October 2024. The VP of Life Safety and Environmental Compliance confirmed the presence of the stains and the poor condition of the resident rooms and hallways, noting that the bright red stains were from spilled punch beverages, while the source of the brown stains was unidentified.
Expired Food Items Not Discarded in Kitchen
Penalty
Summary
The facility failed to adhere to its food safety guidelines by not discarding expired food items in the kitchen, which had the potential to affect all 99 residents. During an observation of the food preparation area, it was found that an 80-ounce opened bag of grits, an unopened 4-pound roll of deli bologna, and a 12-ounce container of ground allspice were all expired and still available for use. Additionally, a 12-ounce container of ground black pepper was found to be open and not properly sealed, posing a risk of contamination. The Certified Dietary Manager (CDM) confirmed during interviews that these items were expired and had not been discarded, and the black pepper was improperly sealed.
Failure to Implement Baseline Care Plans for COVID-19 Positive Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for residents admitted with active COVID-19 infections, as required by their policy. The policy mandates that a baseline care plan, which includes instructions for effective and person-centered care, be developed within 48 hours of a resident's admission. However, for four residents with active COVID-19 infections, the facility did not create or implement such plans. This oversight was evident in the cases of residents who were admitted with COVID-19 and other health issues such as shortness of breath, fatigue, muscle weakness, hypertension, difficulty walking, and seizures. Despite physician orders indicating the need for isolation droplet precautions and regular vital signs monitoring, the baseline care plans did not reflect these requirements. The deficiency was further highlighted during an interview with the MDS/Care Plan Coordinator, who confirmed that the baseline care plans for the affected residents did not address the need for isolation or quarantine. This omission failed to alert employees of the necessary precautions, such as wearing personal protective equipment (PPE), to prevent and control the spread of COVID-19 within the facility. The lack of appropriate baseline care plans for these residents with active COVID-19 infections represents a significant lapse in the facility's adherence to its own policies and procedures.
Failure to Revise Care Plans for COVID-19, Falls, and Code Status
Penalty
Summary
The facility failed to ensure timely revisions of care plans for residents who tested positive for COVID-19 during an outbreak. Specifically, the care plans for ten residents were not updated promptly to include COVID-19 isolation requirements and personal protective equipment (PPE) usage as recommended by the CDC. This oversight occurred despite physician orders indicating the need for isolation and PPE. The delay in updating care plans ranged from two to ten days after a positive COVID-19 test, which did not align with the facility's policy of revising care plans when there is a change in a resident's condition. Additionally, the facility did not revise the care plan for a resident identified as a fall risk. Despite an incident where the resident fell, the care plan was not updated to include new interventions such as non-skid footwear or educational signage. Interviews with staff revealed a lack of awareness regarding the resident's fall risk status, and the resident's Kardex did not reflect the necessary fall interventions. This lack of communication and documentation contributed to the deficiency in addressing the resident's fall risk. Furthermore, the facility failed to update the care plan for a resident whose code status changed from full code to Do Not Resuscitate (DNR). The care plan continued to reflect the incorrect code status, which was confirmed by the MDS-Care Plan Coordinator. This discrepancy between the resident's advance directive and the care plan highlights a failure to ensure that critical information is accurately documented and communicated within the facility.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in two of the four medication carts reviewed. On the A-Wing medication cart, an unopened box of Lorazepam liquid for a resident with severe cognitive impairment was found stored at room temperature instead of in the refrigerator as required. The medication had been on the cart since delivery and was confirmed by the LPN/Risk Manager to have been improperly stored. The pharmacist indicated that the medication would lose effectiveness if not refrigerated and should be discarded after being stored at room temperature for three days. On the C-Wing medication cart, two house stock medications used to treat constipation, Lactulose and Polyethylene Glycol, were found opened and undated. An LPN confirmed that these medications were not stored properly. The facility's policy on medication storage was reviewed, which mandates that medications be stored in medication rooms or carts with proper sanitization, temperature, and moisture control, and that medications requiring refrigeration be stored in designated refrigerators.
Incorrect Tube Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct tube feeding formula as ordered by the physician for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had a history of stroke, epilepsy, type 2 diabetes, gastrointestinal bleed, dysphagia, and aphasia, was supposed to receive Glucerna 1.5 at 70 milliliters per hour. However, on January 1, 2025, the resident was mistakenly given Osmolite 1.2, a different tube feeding formula, for approximately 10 hours. This error was discovered by an LPN the following morning, and the correct formula was administered immediately thereafter. The incident was reported to the Director of Nursing and the Medical Director, who confirmed that the resident did not exhibit any signs of distress or discomfort following the administration of the incorrect formula. The facility's policy on feeding tube guidelines emphasizes the importance of administering enteral nutrition as per the practitioner's orders, which was not adhered to in this case. The Executive Director of Nursing expressed that it was expected for nurses to follow the physician's orders accurately.
Failure to Maintain Resident Dignity by Covering Catheter Bag
Penalty
Summary
The facility failed to protect a resident's right to dignity by not covering an indwelling catheter drainage bag, leaving it visible to the public. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder, malignant neoplasm of the urethra, and acute kidney failure, had a moderate cognitive impairment as indicated by a BIMS score of 11. The comprehensive care plan for the resident specified that a privacy bag should be provided to cover the drainage bag at all times. However, during an observation, it was noted that the resident's urinary drainage bag was uncovered and visible from the hallway. A registered nurse confirmed the absence of a privacy dignity cover, resulting in the direct visibility of the urinary drainage bag.
Failure to Protect Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information on two of its hallways, D-Wing and C-Wing. On D-Wing, a computer screen on a medication cart was left unattended and unlocked, displaying residents' personal health information. Registered Nurse B confirmed that the screen was not secured, allowing unauthorized individuals potential access to sensitive information. On C-Wing, a resident roster containing sensitive health information was left visible on top of a medication cart. Licensed Practical Nurse A acknowledged that the information was not covered, admitting that she forgot to secure it before leaving the cart. These incidents indicate lapses in following the facility's policies on maintaining the confidentiality of residents' health information.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to deficiencies in care. Resident #36, who had severe cognitive impairment and a gallbladder drain, did not have this critical medical intervention included in their care plan. This oversight was confirmed by the MDS Care Plan Coordinator, who acknowledged the omission during a review of the resident's care plan. Resident #506, who was cognitively intact, tested positive for COVID-19, yet their care plan lacked any interventions related to the infection. Despite having physician's orders for isolation precautions, the care plan was not updated to reflect these necessary interventions. The Director of Nursing confirmed the failure to develop a person-centered care plan for the resident's COVID-19 infection. Additionally, the facility failed to implement care plan interventions for Resident #606, who required one-on-one supervision due to inappropriate sexual behaviors. Observations revealed that the resident was left unsupervised, contrary to the care plan's requirements. Staff members, including CNAs, were not informed of the need for constant supervision. Similarly, Resident #93, who required assistance with meals, was not provided with the necessary support, as evidenced by uneaten meals and staff interviews indicating a lack of awareness of the resident's needs. The MDS Care Plan Coordinator confirmed that the care plan for meal assistance was not implemented.
Failure to Maintain Sanitary Conditions for Respiratory Equipment
Penalty
Summary
The facility failed to maintain and store oxygen equipment in a clean and sanitary condition for two residents. Resident #39, who was admitted with diagnoses including Dementia, Skin Cancer, Depression, and Low Back Pain, was observed on two separate occasions with a nebulizer mask lying uncovered on the nightstand, not stored in a sanitary condition. Licensed Practical Nurse (LPN) C confirmed the unsanitary storage of the nebulizer mask, which was available for resident use. Resident #59, admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Kidney Disease, and Shortness of Breath, had multiple nebulizer masks in the room, some of which were stored in bags with various dates. One mask, dated 9/22/2024, was observed with a cloudy substance on its surface, attached to the nebulizer machine, and not stored in a bag. LPN A confirmed that the mask was soiled, out of date, and not stored in a sanitary condition. LPN A also stated uncertainty about the cleaning schedule and who was responsible for changing the masks.
Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of bed rails for a resident prior to their implementation. The facility's policy requires that a physician or nurse practitioner provide written or verbal orders for residents' care and needs, including the use of bed rails. However, for one resident, who was admitted with diagnoses including Epilepsy, Dehydration, Cerebral Palsy, and Protein-Calorie Malnutrition, the facility did not secure a physician's order for bed rails until after they were already in use. This oversight was confirmed through a review of the resident's medical records and interviews with the facility's nursing staff. The resident had a comprehensive care plan that included the use of padded full side rails for protection against rocking behaviors and seizure activity. Observations confirmed that the resident's bed had padded full bed rails in place before a physician's order was obtained. Interviews with the Assistant Director of Nursing and the Director of Nursing further confirmed that the necessary physician's order was not obtained prior to the use of the bed rails, indicating a lapse in following the facility's policy and procedures for bed rail usage.
Incomplete Pharmacy Review Records for Residents
Penalty
Summary
The facility failed to maintain complete records of pharmacy reviews and the provider's responses to irregularities identified by the pharmacist for two residents. Resident #37, who was admitted with multiple diagnoses including Rheumatoid Arthritis, Chronic Respiratory Failure, and Depression, was found to have medication irregularities noted by the pharmacist on several occasions. However, the medical record did not include separate documents of these irregularities along with the provider's responses. Similarly, Resident #71, admitted with conditions such as Delusional Disorder and Dementia, also had medication irregularities identified by the pharmacist on multiple dates, but the facility did not maintain records of the provider's responses to these irregularities. Interviews with facility staff, including the Medical Record Clerk and the Administrator, confirmed the absence of documentation regarding the pharmacist's recommendations and the provider's responses for both residents. The Vice President of Clinical Services also acknowledged that the facility did not have complete records of the monthly pharmacist reviews and recommendations for these residents, indicating a lapse in maintaining a system of medication records that allows for accurate reconciliation and follow-up on identified pharmaceutical concerns.
Inaccurate Facility Assessment Fails to Reflect Resident Needs
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment to reflect the needs and services provided, which had the potential to affect two residents. The assessment, dated July 18, 2024, did not account for the ethnic, cultural, or personal preferences of the residents, as it stated that no resident fell outside the homogenous local culture and language. However, this was not the case for two residents who had specific needs that were not documented in the assessment. One resident, admitted with diagnoses including Major Depressive Disorder, Anxiety, Intellectual Disability, and Autism, identified as transgender and preferred to be addressed with female pronouns and to dress in female clothing. This preference was documented in her comprehensive care plan but not reflected in the facility assessment. Another resident, admitted with Cerebral Infarction and Dementia, spoke only Russian and required a translator for communication, which was also not captured in the facility assessment. The facility administrator confirmed that the assessment was not accurate and did not reflect these residents' specific needs.
Documentation and Transcription Errors in COVID-19 Testing and Medication Administration
Penalty
Summary
The facility failed to accurately document COVID-19 test results for five residents, leading to inconsistencies in medical records. For several residents, including those with cognitive impairments, there was a lack of documentation for positive COVID-19 test results, despite physician orders and care plans indicating positive diagnoses and necessary precautions. In one case, a resident's test result was incorrectly documented as negative, despite a positive diagnosis and subsequent isolation measures. Additionally, the facility did not obtain a timely urinalysis for a resident with altered mental status, despite multiple orders from nurse practitioners. The nursing staff attempted to collect the urine sample but failed to document their attempts or notify the provider of the difficulties encountered. This resulted in a significant delay in obtaining the necessary test results, which were crucial for diagnosing and treating a potential urinary tract infection. Furthermore, the facility failed to transcribe a physician's order accurately for a resident's medication. Although the correct dosage of Lexapro was administered, the medication administration record did not reflect the updated order for over a year. This transcription error was confirmed by the facility's VP of Clinical Services and the pharmacist, who had processed the correct order. The discrepancy between the administered dosage and the documented order highlights a significant lapse in medication management and record-keeping.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey agency as required by their policy. The policy mandates that any alleged violations involving abuse must be reported to the state agency immediately, but no later than two hours after the allegation is made. In this case, Resident #1, who was cognitively intact with a BIMS score of 15, was involved in an incident where an EMT reported to an LPN that the ER doctor documented vaginal bruising and tearing. However, the facility's investigation found no concerns during a skin assessment, and interviews with the resident and the ER doctor revealed no allegations or documentation of sexual abuse. The facility deemed the allegation as malicious gossip and unsubstantiated, and therefore, did not report it to the State Licensing and Certification Agency. Resident #1 had been admitted to the facility with diagnoses including Unspecified Psychosis, Major Depressive Disorder, and Anxiety. The resident was sent to the ER for evaluation after expressing thoughts of self-harm. Upon return, the EMT's report of potential sexual abuse was not substantiated by further investigation. The facility administrator confirmed that the allegation was not reported because it was considered malicious gossip. This inaction led to a deficiency as the facility did not adhere to its policy of timely reporting alleged abuse to the appropriate authorities.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 43 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Church Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Place Kingsport | 6.8 mi | ★★★★★ | 6 | 0 |
| Orchardview Post-acute And Rehabilitation Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Nova Health And Rehab | 11.3 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Kingsport | 12.4 mi | ★★★★★ | 2 | 0 |
| Holston Rehabilitation And Care Center | 12.7 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Church Hill Post-acute And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.