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Deficiency Records for Hendricks Community Hospital
A list of the most recent deficiencies for Hendricks Community Hospital. 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 Hendricks Community Hospital. 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-30 | 2024-07-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-30 | 2024-07-31 | N |
| 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 | 2024-05-30 | 2024-07-31 | 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 | 2024-05-30 | 2024-07-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-30 | 2024-07-31 | N |
| Have a Compliance and Ethics Program. | Health | 2024-05-30 | 2024-07-31 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-30 | 2024-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-30 | 2024-07-31 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-30 | 2024-07-29 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-05-30 | 2024-07-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-19 | 2023-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-07-15 | 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 | 2023-04-19 | 2023-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-19 | 2023-07-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-18 | 2023-07-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-19 | 2023-07-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-19 | 2023-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-19 | 2023-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-25 | 2022-12-23 | 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 | 2022-01-13 | 2022-03-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-30 | 2021-11-18 | 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 | 2021-09-30 | 2021-11-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-09-30 | 2021-11-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-30 | 2021-11-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-30 | 2021-11-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-28 | 2021-11-10 | N |
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