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Inspection visit

Inspection

Hendricks Community HospitalCMS #24546713 citations on this visit
13 citations recorded

Citations

13 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.

  • 0640GeneralS&S Dpotential for harm

    F640 - Automated data processing requirement-

    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0727GeneralS&S Fpotential for harm

    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.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0867GeneralS&S Fpotential for harm

    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.

  • 0868GeneralS&S Fpotential for harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0131GeneralS&S Fpotential for harm

    Meet requirements for sections of health care facilities separated by fire resistive construction.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0511GeneralS&S Fpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0711GeneralS&S Fpotential for harm

    F711 - Physician Visits

    Provide a written emergency evacuation plan.

  • 0926GeneralS&S Fpotential for harm

    F926 - Establish policies, in accordance with applicable Federal, State, and

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

FAQ · About this visit

Common questions about this visit

What happened during the April 30, 2025 survey of Hendricks Community Hospital?

This was a inspection survey of Hendricks Community Hospital on April 30, 2025. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Hendricks Community Hospital on April 30, 2025?

Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."

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

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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.