Inspection visit
Inspection
Citations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F895 - Definitions
Have a Compliance and Ethics Program.
F944 - Quality assurance and performance improvement
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
FAQ · About this visit
Common questions about this visit
What happened during the May 30, 2024 survey of Hendricks Community Hospital?
This was a inspection survey of Hendricks Community Hospital on May 30, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hendricks Community Hospital on May 30, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have proper medical gas storage and administration areas."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.