Madison, IN

Hickory Creek At Madison

4-star overall rating with 4-star inspections with 3 recent health deficiencies

1945 Cragmont St, Madison, IN

(812) 273-4696

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

36

Certified beds

Average residents

34

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

1992-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

91 facilities

Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.13

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.31

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.19

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.83

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

2.67

CMS adjusted total nurse staffing hours

Case-mix index

1.70

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,639

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.14

Composite VBP score used to determine payment impact.

Payment multiplier

0.9841

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.23

Baseline 57.14% · Performance 42.31% · Measure score 5.23 · Achievement 5.23 · Improvement 4.09

Adjusted total nurse staffing

0

Baseline 2.78 hours · Performance 2.54 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.12%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 6.96%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.03	1.02 About the same
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 40
Staff flu vaccination coverage	62.5%	42% 20.5 pts better	Numerator 25 · Denominator 40
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	1.6 0.7 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.5 0.2 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	91.0%	93.6% 2.6 pts worse	93.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 90.0% · Q3 90.0% · Q4 93.3% · 4Q avg 91.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.4% 4.6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.8% 0.5 pts better	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.3% · Q3 3.3% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	8.0%	24.6% 16.6 pts better	11.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.7% · Q3 16.7% · Q4 4.8% · 4Q avg 8.0%
Percentage of long-stay residents who lose too much weight	1.9%	5.6% 3.7 pts better	5.4% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 1.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.4%	23.5% 7.9 pts worse	19.6% 11.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 34.6% · Q3 34.6% · Q4 25.0% · 4Q avg 31.4%
Percentage of long-stay residents who received an antipsychotic medication	8.6%	14.8% 6.2 pts better	16.7% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 7.7% · Q3 7.7% · Q4 4.0% · 4Q avg 8.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	8.7%	13.3% 4.6 pts better	16.3% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.7%	11.7% 8 pts better	14.9% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 4.8% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.4% 0.2 pts worse	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.2% 1.2 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.3%	24.2% 8.9 pts better	19.8% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 3.7% · Q3 17.7% · Q4 19.7% · 4Q avg 15.3%
Percentage of long-stay residents with pressure ulcers	1.1%	4.1% 3 pts better	5.1% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.3% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	78.7%	81.6% 2.9 pts worse	81.7% 3 pts worse	Short Stay · 2024Q4-2025Q3 · Q3 81.5% · Q4 78.1% · 4Q avg 78.7%
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	1.3% 0.6 pts worse	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 1.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-18 · Fire 2025-09-18

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-10-25 · Fire 2024-10-25

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-09-15 · Fire 2023-09-15

2 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-10-25

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2024-11-19

F · Potential for more than minimal harm 2023-09-15

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-10-26

F · Potential for more than minimal harm 2023-09-15

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2023-10-26

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-10-10

D · Potential for more than minimal harm 2025-09-18

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 2025-10-10

D · Potential for more than minimal harm 2025-09-18

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-10-10

D · Potential for more than minimal harm 2024-10-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-11-10

D · Potential for more than minimal harm 2024-03-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-04

E · Potential for more than minimal harm 2023-09-15

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 2023-10-06

D · Potential for more than minimal harm 2023-09-15

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2023-10-06

Penalties and ownership

What sits behind the stars

Ownership

Henry County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 31 facilities 2013-08-01

American Senior Communities LLC

Operational/Managerial Control · Organization

0% 89 facilities 2021-03-01

Burns, Markietta