HENDRICKS COMMUNITY HOSPITAL
503 E LINCOLN STREET, HENDRICKS, MN, 56136 · 5072753134
Legal business name: HENDRICKS COMMUNITY HOSPITAL ASSN & RETIREMENT HOME
On the CMS record
- Overall rating (CMS)
- 1 / 5
- Health inspection rating
- 3 / 5
- Staffing rating
- 1 / 5
- Certified beds
- 48
- Ownership type
- Non profit - Corporation
Inspection findings on record (26)
Quoted exactly as CMS published them. We do not rewrite findings.
— Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
— Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
— Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
— Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
— Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
— Pharmacy Service Deficiencies
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.
— Nursing and Physician Services Deficiencies
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.
Recorded as corrected on .
— Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Recorded as corrected on .
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
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.
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Administration Deficiencies
Have a Compliance and Ethics Program.
Recorded as corrected on .
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Administration Deficiencies
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 245467