Church Home Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Church Home Rehabilitation and Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF758Mar 14, 2024

  Based on record reviews, staff interviews, and review of the facility policy titled Psychotropic Medication Use, the facility failed to ensure three residents (R) (R26, R60, and R17) of five residents reviewed for unnecessary medication were being monitored for behaviors while taking psychotropic medications. Findings Include: Review of the facility policy titled Psychotropic Medication Use, dated July 2022 revealed 3. Psychotropic medication management includes: d. adequate monitoring for efficacy and adverse consequences; and, e. preventing, identifying and responding to adverse consequences. 1. […]

• No harm, potential for more than minimal, isolatedF609Jul 31, 2025

  Based on observations, staff interviews, record review, and a review of the facility's policy titled Abuse Investigation and Reporting, the facility failed to report to the State Survey Agency (SA) a fall with major injury as required within two hours and in a timely manner for one of 46 sampled residents (R) (R9.) Findings Include:Review of the policy titled Abuse Investigation and Reporting, revised July 2017, section Reporting, documented 2. Alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. TWO (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. […]

• No harm, potential for more than minimal, isolatedF880Jul 31, 2025

  Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene and Handling Clean Linen, the facility failed to ensure proper infection control practices were followed during observations of dining and clean laundry pass. This deficient practice had the potential to increase the risk of the spread of infections due to cross-contamination. The facility census was 74. Findings include: Review of the facility policy titled “Hand Hygiene,” dated 5/1/2025, revealed the “Policy” section stated, “All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff.” The “Policy Explanation and Compliance Guidelines” section included, “1. […]

• No harm, potential for more than minimal, isolatedF609Mar 14, 2024

  Based on resident and staff interviews, record review, and review of the facility policy titled Abuse Investigation and Reporting, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime (staff to resident verbal abuse) in accordance with section 1150B of the Act and failed to report the allegation of verbal abuse to the State Survey Agency (SSA) for one resident (R) (R52) of two residents reviewed for abuse. These failures had the potential to contribute to further verbal abuse and possible psychosocial harm for R52. Findings include: Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, Reporting section revealed All alleged violations involving abuse, neglect, exploitation, or mistreatment . […]

• No harm, potential for more than minimal, isolatedF755Mar 14, 2024

  Based on record review, staff interviews, and review of the facility policy titled Medication Ordering and Receiving from Pharmacy, the facility failed to ensure a routine drug was provided as ordered for one resident (R) (R60) of five residents reviewed for unnecessary medications. The failure to administer an ordered antipsychotic medication had the potential to cause increased behavioral symptoms and psychosocial harm for R60. Findings include: Review of the undated Medication Ordering and Receiving from Pharmacy policy revealed, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medications at least 3 days in advance of need to assure an adequate supply is on hand . New medications . […]