Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hendricks Community Hospital during CMS and state inspections, most recent first.
The facility did not provide RN coverage for at least 8 consecutive hours on several days, as required by regulation. Staffing records showed gaps in RN coverage, and interviews with the DON, administrator, and HR confirmed ongoing difficulties in hiring and retaining RNs despite recruitment efforts.
The facility did not ensure that data submitted to the QAPI committee was analyzed or documented, and failed to establish goals, action plans, or data collection methods for identified issues such as falls and quality indicators. Leadership confirmed that no thorough analysis or measurable outcomes were completed, affecting all residents.
The facility did not have formal Performance Improvement Projects (PIPs) in place as part of its QAPI program, with no documented goals, action plans, or data analysis for identified high-risk or problem-prone areas. This failure was confirmed by the DON, administrator, and QAPI director, and was not in accordance with the facility's QAPI policy.
The QAPI committee did not document attendance at meetings, failed to ensure regular infection control reports from the IP, and did not review State Agency or incident reports as required. Meeting minutes lacked evidence of required data presentations and discussions, and interviews confirmed the absence of documentation for these critical quality assurance activities.
A resident's Death in Facility MDS assessment was not submitted within the required timeframe. The assessment was completed and locked in the electronic health record, but not validated or transmitted, resulting in it being marked as completed rather than accepted. The new MDS coordinator was unaware of the outstanding assessment due to a lack of review of prior submissions, and the DON expected timely tracking and submission of all MDS assessments as per facility policy.
A resident with severe cognitive impairment and a history of DVT was prescribed Eliquis, but the care plan and EMAR did not include instructions or monitoring for anticoagulant side effects or increased bleeding risk. Staff interviews confirmed the omission, and facility policy required such monitoring to be included in the care plan.
A resident with severe cognitive impairment and multiple diagnoses, including DVT and dementia, was prescribed Eliquis without any documented instructions for monitoring side effects in the EMAR or care plan. Interviews with LPN, DON, and MDS nurse confirmed that monitoring for bleeding and other side effects was not included, despite facility policy requiring such monitoring for anticoagulant use.
The facility did not maintain thorough infection control surveillance, as documentation for three residents with influenza symptoms lacked evidence of implemented precautions or resolution of symptoms. Additionally, two staff members returned to work after illness without proper clearance or follow-up, and one resident did not receive a complete TB screening as required.
The facility failed to maintain the required RN coverage of 8 consecutive hours a day, 7 days a week, as evidenced by gaps in staffing schedules for February, March, and April 2024. Despite efforts by the LPN, administrator, and HR to recruit RNs through job postings and fairs, the facility continued to experience staffing shortages, leading to the need for an RN waiver.
The QAPI committee failed to identify and address specific concerns, affecting the quality of life and care for 46 residents. A PIP for medication administration lacked essential components, and no PIPs were implemented from July 2023 to March 2024. The DON acknowledged the need for improvements in the current PIP.
A facility failed to maintain an effective compliance and ethics program, as evidenced by a registered nurse instructing an LPN to sign a narcotic documentation form for a count he did not witness. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to. Additionally, the RN lacked documentation of ethics training, and the facility did not have an active ethics committee.
A resident experienced a fall while being assisted by a nursing assistant, but the facility failed to notify the resident's family and physician. The incident occurred when the resident attempted to grab a bag containing soiled pants, resulting in a fall. Despite the resident denying injury, no notification was made to the family or physician. Days later, a hip fracture was discovered, and the family expressed concerns about the lack of timely notification and medical assessment.
A resident with severe cognitive impairment and multiple diagnoses was subjected to a seatbelt restraint without a plan for reduction or removal. Despite the care plan's goal to decrease restraint usage, no specific interventions were in place. Observations showed the resident could not remove the restraint independently, and staff confirmed no plan was developed due to staffing issues. The facility's restraint policy was not adhered to, as no systematic reduction plan was implemented.
A resident with a history of congestive heart failure and other conditions did not receive proper oxygen administration due to a lack of specified flow rate in the physician's order. Observations showed inconsistent oxygen delivery, and staff interviews revealed confusion about the resident's current order. The facility's policies requiring specific oxygen order details were not followed, leading to inappropriate reliance on staff judgment for oxygen flow rate.
A resident with moderate cognitive impairment was administered risperidone without a qualifying diagnosis, contrary to the facility's policy. The resident exhibited behaviors such as calling out for help and frequent bathroom requests, but no root cause analysis was conducted to understand these behaviors. Interviews with the DON and administrator confirmed the lack of an appropriate diagnosis for the antipsychotic use.
The facility failed to ensure that one of its emergency kits did not contain expired medications and did not maintain a system for the disposition of controlled substances. Expired medications, including Lorazepam, Hydrocodone/APAP, and Tramadol, were found in the E-kit, and the pharmacist confirmed that the expired medications were not replaced. The director of nursing expected monthly checks by the pharmacy and verification by nursing staff, as per facility policy, but these procedures were not followed.
The facility did not provide mandatory training on its QAPI Program, affecting all 46 residents. Staff interviews revealed a lack of awareness and understanding of the facility-specific QAPI program, with some attending meetings or receiving generalized online training. The Director of Nursing admitted that the training was insufficient and that staff were not adequately educated on the program's requirements or communication processes.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week, as required by federal regulation CFR 483.35(b)(1). Review of nursing staff schedules for February, March, and April 2025 revealed that there was no 8-hour consecutive RN coverage on two days in March and one day in April. The deficiency was identified through examination of staffing records, which showed gaps in RN coverage on specific dates. Interviews with the DON, administrator, and human resources officer confirmed ongoing challenges in hiring and retaining RNs to meet the required coverage. The DON stated that the scheduler attempted to fill open shifts and notified management of any call-ins or unfilled shifts, and that an RN was on call or could be assigned as needed. The administrator and HR officer described efforts to recruit RNs through various channels, including online job postings and local advertisements. Despite these efforts, the facility was unable to ensure consistent RN coverage as required by policy and regulation.
Failure to Analyze and Document QAPI Data and Actions
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance Performance Improvement (QAPI) committee was properly analyzed and documented, resulting in a lack of oversight for identified problem areas. Review of QAPI meeting minutes from April 2024 through March 2025 revealed that while issues such as falls, family notification for therapy, completion of forms, resident toileting, and repositioning were identified, there were no documented goals, action plans, methods for data collection, or analysis of the information. Several meetings did not include any review of ongoing projects or associated data, and even when quality indicators were discussed, there was no follow-through with measurable goals or action plans. An interview with facility leadership, including the QAPI director, administrator, and DON, confirmed that a thorough analysis of data, including the establishment of measurable goals, plans, or outcomes, had not been completed. The facility's QAPI policy required tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing causes, developing corrective action plans, and monitoring outcomes, but these components were not implemented as required. This deficiency had the potential to affect all 47 residents in the facility.
Lack of Formal Performance Improvement Projects in QAPI Program
Penalty
Summary
The facility failed to provide evidence of an ongoing Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, as required by their Quality Assurance and Performance Improvement (QAPI) program. Review of QAPI meeting minutes from April 2024 through March 2025 showed no PIP projects with documented goals, action plans, data collection, or analysis for areas or issues identified as needing improvement. During an interview, the Director of Aging Services, the facility administrator, and the DON confirmed that while there had been some previous PIP projects, no formal PIP plans had been developed in the past year. The facility's QAPI policy requires the identification and correction of high-risk, high-volume, or problem areas, but this process was not followed, potentially affecting all 47 residents in the facility.
QAPI Committee Lacks Documentation and Required Review Processes
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee failed to meet several regulatory requirements over four reviewed quarters. Meeting minutes from multiple dates showed that the committee did not document attendance, making it impossible to confirm if required members, such as the DON, medical director, infection preventionist (IP), and administrator, were present. The minutes only included a typed list of members without specifying who attended or was absent. Additionally, there was no evidence that the committee received or reviewed regular reports from the IP regarding infection control activities, process and outcome surveillance, outbreaks, staff illness, or the Antibiotic Stewardship Program (ASP). The QAPI director confirmed that while the IP sometimes gave verbal updates, these were not documented, and there was no record of discussion, goals, or plans for improvement. Furthermore, the committee did not document the review of State Agency (SA) or incident reports, as required by facility policy. Interviews with the QAPI director, administrator, and DON revealed uncertainty about whether these reports were discussed with the medical director and confirmed the absence of documentation regarding their review. The facility's QAPI policy mandates maintaining documentation to confirm compliance with CMS requirements, including the composition of the committee and the review of relevant reports, but these requirements were not met during the period reviewed.
Failure to Timely Submit Death in Facility MDS Assessment
Penalty
Summary
The facility failed to ensure timely submission of a Death in Facility Minimum Data Set (MDS) for one resident. The resident's last scheduled MDS assessment was submitted and validated on 11/26/24. However, the Death in Facility MDS, which was signed and locked by the responsible party on 1/7/25, was not successfully submitted or transmitted. The electronic health record indicated the assessment was marked as completed rather than accepted, showing it had not been submitted as required. A registered nurse (RN) who took over as the MDS coordinator in mid-January 2025 reported that prior to her tenure, multiple individuals had completed MDS assessments. The RN identified that the person responsible for the resident's final assessment failed to validate and submit the assessment, which would have sent it to the submission file in the Meditech system. The RN had not reviewed previous MDS submissions and was unaware of the outstanding assessment until the survey. The director of nursing (DON) stated that her expectation was for the MDS coordinator to track Assessment Reference Dates and ensure completion, validation, and submission of MDS assessments within required time frames. Facility policy required assessments to be completed and submitted according to the MDS ARD and within required time frames.
Failure to Update Care Plan for Anticoagulant Side Effect Monitoring
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and multiple diagnoses including a history of stroke, DVT, depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. Review of the resident's care plan showed it addressed risks related to falls and side effects of psychotropic medications but did not mention anticoagulant use, increased bleeding risk, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that the care plan and EMAR lacked references to anticoagulant use and side effect monitoring. Staff acknowledged that care plans should include instructions for monitoring for bleeding and other side effects when a resident is on anticoagulant therapy. Facility policies also required assessment and monitoring for adverse drug reactions and complications such as bleeding, but these were not reflected in the resident's care plan or EMAR.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and a history of stroke, deep venous thrombosis (DVT), depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. The resident's care plan identified risks related to other medications but did not address anticoagulant use, increased risk for bleeding, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that instructions for monitoring side effects should be present in the electronic medication administration record (EMAR) and the care plan, but were absent in both for this resident. The facility's own policy required staff to assess for adverse drug reactions and monitor for complications such as excessive bruising or bleeding. Despite this, there was no documentation or instruction in the care plan or EMAR to guide staff in monitoring for anticoagulant side effects for this resident.
Deficient Infection Control Surveillance and Employee Health Monitoring
Penalty
Summary
The facility failed to maintain a comprehensive and ongoing infection control surveillance program, as evidenced by incomplete documentation and lack of implementation of appropriate precautions for residents with respiratory symptoms. For three residents who exhibited symptoms such as fever, cough, myalgia, and were diagnosed with influenza, the surveillance forms did not indicate whether any infection control precautions were implemented, what type of precautions were used, or when these precautions were started or ended. Progress notes for these residents also lacked clear documentation regarding the initiation and duration of quarantine or isolation measures, despite ongoing symptoms and confirmed influenza diagnoses. Additionally, the facility did not adequately monitor or enforce return-to-work protocols for staff members who reported illness. Two staff members called in with symptoms of vomiting, diarrhea, and fever, but the documentation did not consistently include illness forms or appropriate clearance by a licensed nurse before returning to work. In one case, a staff member returned to work the day after reporting gastroenteritis symptoms, contrary to recommended guidelines, and there was no evidence of follow-up or assessment prior to their return. The facility also failed to complete required tuberculosis (TB) screening for one resident. Although a TB skin test was administered upon admission, the results were not read, and a baseline symptom screening was not completed prior to testing. A second TB skin test was later administered and read with a negative result, but the initial lapse in protocol was confirmed by the DON, who acknowledged the oversight in both reading the test and completing the symptom screening.
Non-Compliance with RN Coverage Requirements
Penalty
Summary
The facility was found to be non-compliant with the requirement for registered nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as per CFR 483.35 (b)(1). The review of nursing staff schedules for February, March, and April 2024 revealed that there were several days in each month where the facility failed to provide the required RN coverage. Specifically, there were 6 days in February, 2 days in March, and 2 days in April where the facility did not have an RN on duty for the required 8 consecutive hours. Interviews with facility staff, including the LPN responsible for scheduling, the administrator, the human resources representative, and the director of nursing (DON), highlighted the ongoing challenges in maintaining adequate RN staffing levels. The LPN reported notifying management of call-ins and attempting to fill open shifts, while the administrator and HR representative described efforts to recruit RNs through various channels, including job postings and job fairs. Despite these efforts, the facility continued to struggle with staffing shortages, necessitating the continuation of an RN waiver to remain in compliance.
QAPI Committee Fails to Address Facility Concerns
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to effectively identify and address specific concerns within the facility, impacting the quality of life and care for 46 residents. The committee did not implement an action plan to correct identified issues or ensure the development and oversight of systems to maintain quality standards. A performance improvement plan (PIP) was created to observe medication administrations in the dining room, but it lacked essential components such as a target date, observation dates, and times, as well as interventions to analyze underlying causes and opportunities for improvement. During an interview, the Director of Nursing (DON) revealed that the facility used an online quality scorecard to track PIPs but had not implemented any from July 2023 to March 2024. The DON had encouraged the administration and department heads to identify improvement areas and create PIPs, but only one PIP related to medication administration was added in April. The DON acknowledged that the current PIP needed improvements, including audits and consistent data for performance analysis. The facility's QAPI policy from February 2024 stated that the program was to develop and implement performance improvement activities, which was not effectively executed.
Deficiency in Compliance and Ethics Program
Penalty
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by an incident involving a registered nurse (RN) and a licensed practical nurse (LPN). On two occasions, the facility's narcotic documentation forms were missing signatures, indicating a lack of proper verification of controlled substance counts. On May 28, 2024, RN-D instructed LPN-E to sign a narcotic documentation form for a count he did not witness. This action was stopped by a surveyor, highlighting a breach in protocol. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to in this instance. Further investigation revealed that RN-D lacked documentation of ethics training upon hire, despite a facility policy requiring such training. Additionally, the facility did not have an active ethics committee, and the director of nursing (DON) was unaware of any regular meetings or the existence of such a committee. The facility's policies emphasize accurate documentation and ethical conduct, yet these were not followed, leading to the deficiency noted by the surveyors.
Failure to Notify Family and Physician After Resident Fall
Penalty
Summary
The facility failed to notify the resident's representative and physician after a witnessed fall involving a resident. On the morning of December 10, 2023, the resident, identified as R48, was combative towards a nursing assistant while being assisted to the toilet. During the incident, the resident attempted to grab a plastic bag containing his soiled pants, resulting in a fall. Although the resident denied injury and refused vital sign checks, there was no documentation indicating that the resident's physician or family were informed of the fall. The incident report and electronic medical records also lacked evidence of notification to the resident's responsible party or physician. Subsequently, on December 14, 2023, the resident was assessed for hip pain, leading to the discovery of a right hip fracture. The family and physician were notified at this point, and the resident was transferred to a regional hospital for further assessment. An interview with a family member revealed that they were unaware of the fall until visiting the resident on December 14, 2023. The family member expressed concerns about the lack of notification and the delay in medical assessment. The Director of Nursing stated that the expectation was for staff to notify both the physician and family within a reasonable time frame, but no policy for incident notification was provided.
Failure to Develop Restraint Reduction Plan for Resident
Penalty
Summary
The facility failed to develop a plan to reduce or discontinue the use of a seatbelt type of restraint for a resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain injury, Alzheimer's disease, and dementia. The resident was dependent on staff for activities of daily living and used a wheelchair with a trunk restraint. Despite the care plan identifying a goal to decrease or eliminate restraint usage, no specific plan or interventions were in place to achieve this goal. Observations revealed that the resident was unable to remove the seatbelt independently, indicating a lack of assessment and planning for restraint reduction. Interviews with facility staff, including the assistant director of nursing and the director of nursing, confirmed that no plan had been developed for the removal of the restraint due to staffing limitations and a lack of attempts to use less restrictive measures. The facility's policy on the use of restraints, which requires a written order from a physician and a plan to systematically reduce or eliminate the need for restraint use, was not followed. The resident's medical record indicated that behaviors had improved with medication, but the restraint remained in place without a clear plan for its removal.
Inadequate Oxygen Administration for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as R3, by not specifying oxygen flow rate parameters in the physician's order and not delivering supplemental oxygen according to the order. R3's medical history included dementia, anxiety, congestive heart failure, and other conditions. The resident's care plan indicated the use of oxygen as needed to maintain oxygen levels above 90%, but the current order lacked a specified flow rate or range, leading to inconsistent oxygen administration. Observations revealed that R3 was inconsistently provided with oxygen, with varying flow rates of 1L, 1.5L, and 2L, despite the absence of a clear order. Staff interviews indicated confusion regarding the resident's oxygen order, with some staff referencing an outdated order for as-needed oxygen at 1L. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lack of a specified flow rate and the inappropriate reliance on staff judgment to determine the oxygen flow rate. The facility's policies required oxygen orders to specify the rate of flow, route, and rationale, which was not adhered to in R3's case. The DON admitted that the provider might be unaware of the resident's oxygen use due to inadequate documentation and communication. This deficiency in respiratory care was compounded by the failure to update the medical record with the correct oxygen order, leading to further inconsistencies in care delivery.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had a qualifying diagnosis for the routine use of an antipsychotic medication. The resident, who had moderate cognitive impairment and required extensive assistance for daily activities, was being administered risperidone, an antipsychotic, for agitation. However, the resident's medical record did not contain a diagnosis that justified the use of this medication according to the facility's policy, which aligns with the Diagnostic and Statistical Manual of Mental Disorders. The resident exhibited behaviors such as calling out for help and frequent requests to use the bathroom, but there was no evidence of a root cause analysis to determine the underlying reasons for these behaviors. Interviews with the Director of Nursing and the administrator revealed that the antipsychotic was prescribed for behaviors like yelling out for assistance and toileting issues, or if the resident was unable to sleep at night. The facility's policy on antipsychotic medication use specifies that such medications should only be used for certain documented conditions, which were not present in this case. The Director of Nursing acknowledged the lack of an appropriate diagnosis for the antipsychotic use, and the administrator expected staff to adhere to the policy for antipsychotic use.
Expired Medications Found in Emergency Kit
Penalty
Summary
The facility failed to ensure that one of its two emergency kits (E-kits) did not contain expired medications and did not maintain a system for the disposition of controlled substances to prevent drug diversion. During an observation, interview, and document review, it was found that the large E-kit in the medication room had an unsigned inventory list indicating expired medications, including Lorazepam, Hydrocodone/APAP, and Tramadol, all with an expiration date of 5/16/24. The E-kit contained expired tablets of these medications, and the registered nurse (RN-D) stated that nurses were supposed to verify the E-kit tag each shift, while the local pharmacy was responsible for monthly checks and removal of expired medications. However, the pharmacist confirmed that the expired medications were not replaced and that the E-kit controlled medications were not checked monthly by the pharmacy. The director of nursing (DON) expressed that her expectation was for the pharmacy to check the E-kit medications monthly and for nursing staff to record controlled substances on the log with each shift for verification. The facility's policy from December 2023 stated that the pharmacy was to complete a monthly audit to verify medication counts and expiration dates. The failure to adhere to these procedures resulted in expired medications remaining in the E-kit, indicating a lapse in the facility's medication management system.
Facility Fails to Provide Specific QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program, affecting all 46 residents. Interviews with various staff members, including LPNs, nursing assistants, and housekeeping aides, revealed a lack of awareness and understanding of the facility-specific QAPI program. Some staff members had attended QAPI meetings or received generalized online training, but they were not informed about specific performance improvement projects or long-term goals. The training provided was not tailored to the facility's identified areas for improvement, action plans, or monitoring processes. The Director of Nursing acknowledged that staff were newly introduced to QAPI meetings and training, and that the online training provided during orientation was insufficient. Staff were not adequately educated on the requirements of the QAPI program or how to communicate their concerns effectively. The expectation was for staff to attend future QAPI meetings to better understand the program and its goals, which aim to improve the quality of care for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hendricks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sylvan Court | 15.6 mi | ★★★★★ | 4 | 0 |
| Avera Sunrise Manor | 21.5 mi | ★★★★★ | 0 | 0 |
| The Neighborhoods At Brookview | 21.9 mi | ★★★★★ | 2 | 0 |
| United Living Community | 23.4 mi | ★★★★★ | 9 | 0 |
| Estelline Nursing And Care Center | 27.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.