Report
TheVardellReport
Church Hill Post-Acute and Rehabilitation Center
Skilled nursing facility and nursing facility
701 West Main Blvd
Church Hill, TN 37642
Report
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The Vardell Report.Church Hill Post-Acute and Rehabilitation Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Church Hill, TN
- Record Period
- 2024–2026
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 6 inspections from September 2024 to August 2026, state surveyors documented 39 findings at Church Hill Post-Acute and Rehabilitation Center; 29 have a recorded correction and 10 await one; CMS lists 2 enforcement actions in the window.
- Inspections
- 6
- 2024–2026, standard and complaint
- Findings
- 39
- Deficiencies cited by state inspectors
- Corrected
- 29
- Of 39 findings, with a recorded correction date
- Penalties
- 2
- 1 fine; payment not published, 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2024 | 2 | 21 | 6 |
| 2025 | 2 | 2 | 0 |
| 2026 | 2 | 16 | 0 |
What the Record Shows
- 29 of 39 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 1 fine of $250,780, its payment not published; denial of payment imposed November 18, 2024, ended February 8, 2025.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, August 7, 2026, recorded 10 findings (most serious: Level E).
What to Ask About
- Residents Taking Their Own Medication, No Recorded Correction
- Needs and Preferences, No Recorded Correction
- Citation F628, No Recorded Correction
- Care Plans, No Recorded Correction
- Care Plan Timing and Review, No Recorded Correction
- Nutrition and Hydration, No Recorded Correction
- Respiratory Care, No Recorded Correction
- Citation F813, No Recorded Correction
- Medical Records, No Recorded Correction
- Citation F849, No Recorded Correction
Report at a Glance
- Facility
- Church Hill Post-Acute and Rehabilitation Center
- Address
- 701 West Main Blvd, Church Hill, TN 37642
- CMS Certification Number
- 445237
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 124
- Ownership
- For profit - Limited Liability company
- Record Window
- September 5, 2024 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
10 findings
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
- F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
6 findings
The same visit included a complaint investigation.
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
- F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level DNo actual harm, potential for moreCorrected Mar 18, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 18, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 8, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
20 findings
The same visit included a complaint investigation.
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level LImmediate jeopardyCorrected Dec 16, 2024
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Level LImmediate jeopardyCorrected Dec 16, 2024
- F837Establish 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.Level LImmediate jeopardyCorrected Dec 16, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level LImmediate jeopardyCorrected Dec 16, 2024
- F880Provide and implement an infection prevention and control program.Level LImmediate jeopardyCorrected Dec 16, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level KImmediate jeopardyCorrected Dec 16, 2024
- F584Honor 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.Level FNo actual harm, potential for moreCorrected Dec 16, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Dec 16, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected Dec 16, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Dec 16, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 8, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F700Try 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.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F838Conduct 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.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 16, 2024
Enforcement Action
Civil money penalty, $250,780 imposed November 18, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 18, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 18, 2024. Status: Closed, February 8, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of November 18, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 20, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Residents Taking Their Own Medication, No Recorded Correction
F554 was cited in August 2026. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F554 across all 6 inspections, oldest to newest - 2
Needs and Preferences, No Recorded Correction
F558 was cited in August 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F558 across all 6 inspections, oldest to newest - 3
Citation F628, No Recorded Correction
F628 was cited in August 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F628 across all 6 inspections, oldest to newest - 4
Care Plans, No Recorded Correction
F656 was cited in November 2024 and August 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F656 across all 6 inspections, oldest to newest - 5
Care Plan Timing and Review, No Recorded Correction
F657 was cited in November 2024, May 2025 and August 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F657 across all 6 inspections, oldest to newest - 6
Nutrition and Hydration, No Recorded Correction
F692 was cited in November 2024, January 2025 and August 2026. This citation covers whether residents get enough food and fluids to stay healthy. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F692 across all 6 inspections, oldest to newest - 7
Respiratory Care, No Recorded Correction
F695 was cited in November 2024, February 2026 and August 2026. This citation covers oxygen, breathing treatments and other respiratory care. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F695 across all 6 inspections, oldest to newest - 8
Citation F813, No Recorded Correction
F813 was cited in August 2026. The agency describes it this way: Have a policy regarding use and storage of foods brought to residents by family and other visitors. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F813 across all 6 inspections, oldest to newest - 9
Medical Records, No Recorded Correction
F842 was cited in November 2024 and August 2026. This citation covers whether resident records are complete, accurate and kept confidential. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F842 across all 6 inspections, oldest to newest - 10
Citation F849, No Recorded Correction
F849 was cited in August 2026. The agency describes it this way: 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. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
242425252626F849 across all 6 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do you decide whether a resident may keep and take their own medications?
Residents Taking Their Own Medication: cited in one inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 02
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in one inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 03
What changed after F628 was cited, and how do you check it now?
Citation F628: cited in one inspections, most seriously at level E. The August 7, 2026 citation has no recorded correction date.
- 04
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 05
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in three inspections, most seriously at level E. The August 7, 2026 citation has no recorded correction date.
- 06
How are weight and fluid intake tracked, and what happens when a resident starts losing weight?
Nutrition and Hydration: cited in three inspections, most seriously at level E. The August 7, 2026 citation has no recorded correction date.
- 07
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in three inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 08
What changed after F813 was cited, and how do you check it now?
Citation F813: cited in one inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 09
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 10
What changed after F849 was cited, and how do you check it now?
Citation F849: cited in one inspections, most seriously at level D. The August 7, 2026 citation has no recorded correction date.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 12
What led to the 2024 fine, and has it been paid?
A $250,780 civil money penalty was imposed November 18, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Tennessee state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection Sep 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection Nov 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection Jan 23, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection May 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection Feb 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Tennessee state survey agency
Inspection Aug 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 445237
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowSeptember 5, 2024 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before September 2024 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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