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Deficiency Records for Churchman Village
A list of the most recent deficiencies for Churchman Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Churchman Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-03-19 | 2024-05-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-03-19 | 2024-05-09 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-03-19 | 2024-05-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-19 | 2024-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-19 | 2024-05-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-19 | 2024-05-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-19 | 2024-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-19 | 2024-05-09 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-03-19 | 2024-05-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-19 | 2024-05-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-03-19 | 2024-05-09 | Y |
| 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. | Health | 2024-03-19 | 2024-05-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-19 | 2024-05-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-19 | 2024-05-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-19 | 2024-05-09 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-19 | 2024-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-19 | 2024-05-09 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-03-19 | 2024-05-09 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-03-19 | 2024-05-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-19 | 2024-05-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-19 | 2024-05-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-14 | 2023-04-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-14 | 2023-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-14 | 2023-04-05 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-03-14 | 2023-04-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-14 | 2023-04-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-17 | 2022-09-14 | N |
| 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. | Health | 2022-08-17 | 2022-09-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-17 | 2022-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-17 | 2022-09-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-17 | 2022-09-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-17 | 2022-09-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-17 | 2022-09-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-17 | 2022-09-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-17 | 2022-09-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-17 | 2022-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-17 | 2022-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-17 | 2022-09-14 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-17 | 2022-09-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-17 | 2022-09-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-16 | 2019-06-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-16 | 2019-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-16 | 2019-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-16 | 2019-06-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-16 | 2019-06-26 | N |
| 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. | Health | 2019-05-16 | 2019-06-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-22 | 2019-06-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-22 | 2019-06-10 | N |
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