Cycle 1
Health 2025-04-30 · Fire 2025-04-30
8 health deficiencies
Top issue: Administration (3 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Hendricks, MN
Hendricks Community Hospital
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
503 E Lincoln Street, Hendricks, MN
(507) 275-3134
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.17
Registered nurse staffing
LPN hours / resident day
0.37
Licensed practical nurse staffing
Aide hours / resident day
2.81
Nurse aide staffing
Weekend hours
3.48
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
96.1%
1.6 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
3.9%
4.5 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.3%
3 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.6% |
4.1%
3.5 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
12.4%
10.7 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
17.5%
3.1 pts worse
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.4% |
22.5%
6.1 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
18.6%
9.5 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.3%
0.1 pts better
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.6%
2.9 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
24.8%
6.8 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
5.4%
4.6 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
88.6%
11.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.9%
1.2 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
9 health deficiencies
Top issue: Administration (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-04-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-04-30
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-29
F · Potential for more than minimal harm
2023-04-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-01
F · Potential for more than minimal harm
2023-04-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-04-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-30
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-04-30
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-04-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-04-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-04-30
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-04-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-04-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-05-30
F727 · Nursing and Physician Services Deficiencies
Health
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.
Not marked corrected
F · Potential for more than minimal harm
2024-05-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-05-30
F895 · Administration Deficiencies
Health
Have a Compliance and Ethics Program.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-30
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-04-19
F727 · Nursing and Physician Services Deficiencies
Health
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.
Not marked corrected
F · Potential for more than minimal harm
2023-04-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-07-15
F · Potential for more than minimal harm
2023-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-15
D · Potential for more than minimal harm
2023-04-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-15
D · Potential for more than minimal harm
2023-04-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-15
Penalties and ownership
What sits behind the stars
Ownership
Engels, John
Corporate Director · Individual
Fier, Amy
Corporate Director · Individual
Johnson, Brittany
Corporate Director · Individual
Mccluskey, Tabb
Operational/Managerial Control · Individual
Molascon, Allen
Corporate Director · Individual
Ness, James
Corporate Director · Individual
Olsen, Travis
Operational/Managerial Control · Individual
Olsen, Travis
Corporate Officer · Individual
Popowski, Dawn
Corporate Director · Individual
Robinson, Vince
Corporate Director · Individual
Shaw, Heather
Corporate Director · Individual
Vaneck, Mark
Corporate Director · Individual
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4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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