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Church Hill Care & Rehab Ctr

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About Church Hill Care & Rehab Ctr

General Information

Legal Business NameVanguard Of Church Hill, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareSeptember 23, 1989 (28 years)
Capacity124
Residents119
Percent Occupied96%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Church Hill Care & Rehab Ctr

Church Hill Care & Rehab Ctr
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Tennessee Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

May 24, 2016 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

February 23, 2016 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

February 3, 2016 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintKeep all essential equipment working safely.
DFewPotential for HarmComplaintReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaintKeep residents' personal and medical records private and confidential.

June 26, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

June 4, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

May 7, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

February 3, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmComplaint+Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Church Hill Care & Rehab Ctr require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 10min
2hr 35min
ReportedExpected
CNA
50min
40min
ReportedExpected
LPN
35min
60min
ReportedExpected
RN
3hr 30min
4hr 15min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

91.2%
95.4%
95.4%
95.4%
93.2%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
91.8%
98.0%
97.0%
94.2%
91.5%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
64.9%
51.3%
43.2%
45.5%
55.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of low risk long-stay residents who lose control of their bowels or bladder
32.6%
30.1%
29.3%
29.8%
36.8%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who received an antianxiety or hypnotic medication
28.3%
24.0%
27.3%
24.2%
21.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents whose ability to move independently worsened
15.2%
12.6%
10.6%
10.6%
18.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who received an antipsychotic medication
14.4%
12.5%
14.8%
15.4%
15.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents whose need for help with daily activities has increased
0.0%
0.0%
1.0%
1.8%
5.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who self-report moderate to severe pain
5.3%
3.1%
12.4%
11.7%
8.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who lose too much weight
2.5%
4.8%
1.2%
0.0%
5.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of high risk long-stay residents with pressure ulcers
1.1%
1.1%
1.1%
2.1%
2.4%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who have depressive symptoms
4.2%
7.1%
8.2%
2.9%
5.4%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents with a urinary tract infection
8.2%
5.9%
5.0%
3.9%
3.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents experiencing one or more falls with major injury
3.2%
5.1%
2.5%
3.7%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
1.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

80.5%
87.4%
83.8%
66.2%
81.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
78.4%
79.2%
79.2%
79.2%
80.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
45.8%
42.7%
53.5%
53.1%
61.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who made improvements in function
3.7%
0.0%
0.0%
3.7%
14.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who self-report moderate to severe pain
2.8%
3.4%
6.2%
3.9%
2.2%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.0%
0.0%
0.0%
0.8%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents with pressure ulcers that are new or worsened