Church Hill Post-Acute and Rehabilitation Center

Hire a qualified full-time social worker in a facility with more than 120 beds.

Ensure that residents are fully informed and understand their health status, care and treatments.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Provide safe and appropriate respiratory care for a resident when needed.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide enough food/fluids to maintain a resident's health.

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.

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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide enough food/fluids to maintain a resident's health.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Keep residents' personal and medical records private and confidential.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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 r…

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Provide safe and appropriate respiratory care for a resident when needed.

Provide and implement an infection prevention and control program.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Respond appropriately to all alleged violations.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.