D-
40/100CHURCH HILL POST-ACUTE AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (CHURCH HILL, Tennessee)
701 WEST MAIN BLVD, CHURCH HILL, Tennessee 37642
Phone: 4233577178
Overview & Bed Count
Certified Beds
124
Avg Residents/Day
84.1
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Hawkins
Sprinkler Systems
Yes
Special Focus
SFF
Abuse Icon
No
CMS Star Ratings
OverallN/A
HealthN/A
StaffingN/A
QualityN/A
Nurse Staffing Check
| Metric | This Facility | Tennessee Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.55 | 0.60 | -0.05 |
| Total Nurse Hours per Resident per Day | 3.64 | 3.82 | -0.18 |
| CMS Staffing Rating | N/A | 2.5/5 | - |
| Nursing Staff Turnover | 51.5% | 48.6% | - |
Health Citation History
39 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-07 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E – Moderate Harm Potential |
| 2026-08-07 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2026-08-07 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | E – Moderate Harm Potential |
| 2026-08-07 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2026-08-07 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2026-08-07 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2026-08-07 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-08-07 | Nutrition and Dietary Deficiencies | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | D – Moderate Harm Potential |
| 2026-08-07 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2026-08-07 | Administration Deficiencies | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D – Moderate Harm Potential |
| 2026-02-12 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2026-02-12 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2026-02-12 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2026-02-12 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2026-02-12 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-02-12 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | D – Moderate Harm Potential |
| 2025-05-05 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2025-01-23 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-11-18 | Nursing and Physician Services Deficiencies | 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 – Immediate Jeopardy |
| 2024-11-18 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | L – Immediate Jeopardy |
| 2024-11-18 | Administration Deficiencies | 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 – Immediate Jeopardy |
| 2024-11-18 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | L – Immediate Jeopardy |
| 2024-11-18 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | L – Immediate Jeopardy |
| 2024-11-18 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2024-11-18 | Resident Rights Deficiencies | 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 – Moderate Harm Potential |
| 2024-11-18 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-11-18 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E – Moderate Harm Potential |
| 2024-11-18 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2024-11-18 | Pharmacy Service Deficiencies | 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 – Moderate Harm Potential |
| 2024-11-18 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-11-18 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2024-11-18 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-11-18 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-11-18 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-11-18 | Quality of Life and Care Deficiencies | 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 – Moderate Harm Potential |
| 2024-11-18 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2024-11-18 | Administration Deficiencies | 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 – Moderate Harm Potential |
| 2024-11-18 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-09-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
Fire Safety Citation History
4 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-12 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2026-02-12 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2024-11-18 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-11-18 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
Total Penalties & Fines
$250,780
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-11-18 | Fine | $250,780 | - |
| 2024-11-18 | Payment Denial | - | 72 days starting 2024-11-28 |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the CHURCH HILL area at no cost.
Find Safe, Vetted Facilities Near CHURCH HILL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the CHURCH HILL area at no cost.
Find Safe, Vetted Facilities Near CHURCH HILL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.