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? |
---|---|---|---|---|
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 |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-28 | 2021-08-03 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-17 | 2021-07-13 | Y |
Respond appropriately to all alleged violations. | Health | 2019-09-19 | 2019-11-17 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-19 | 2019-11-17 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-19 | 2019-11-17 | 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 | 2019-09-19 | 2019-11-17 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-17 | 2019-10-23 | N |