Rochester, IN

Hickory Creek At Rochester

2-star overall rating with 2-star inspections with $14,901 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

340 E 18th Street, Rochester, IN

(574) 223-5100

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

36

Certified beds

Average residents

26

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

1992-03-01

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

1.04

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.64

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.37

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.06

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.68

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.25

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.54

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.74

CMS adjusted RN staffing hours

Adjusted total hours

2.89

CMS adjusted total nurse staffing hours

Case-mix index

1.92

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,908

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

Performance score

14.76

Composite VBP score used to determine payment impact.

Payment multiplier

0.9814

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

2.95

Baseline 65.62% · Performance 51.61% · Measure score 2.95 · Achievement 2.95 · Improvement 2.94

Adjusted total nurse staffing

0

Baseline 3.12 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 15 · 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 7 · 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 42
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 47
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · 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 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.8%	93.6% 1.2 pts better	93.4% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 92.0% · Q3 95.8% · Q4 100.0% · 4Q avg 94.8%
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	5.2%	3.8% 1.4 pts worse	3.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.0% · Q3 4.2% · Q4 4.5% · 4Q avg 5.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	52.3%	24.6% 27.7 pts worse	11.4% 40.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 42.9% · Q3 70.8% · Q4 70.0% · 4Q avg 52.3%
Percentage of long-stay residents who lose too much weight	8.0%	5.6% 2.4 pts worse	5.4% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 13.0% · Q3 0.0% · Q4 5.0% · 4Q avg 8.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	36.8%	23.5% 13.3 pts worse	19.6% 17.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 39.1% · Q3 36.4% · Q4 35.0% · 4Q avg 36.8%
Percentage of long-stay residents who received an antipsychotic medication	20.5%	14.8% 5.7 pts worse	16.7% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · 4Q avg 20.5% · 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	4.4%	13.3% 8.9 pts better	16.3% 11.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.8%	11.7% 5.9 pts better	14.9% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 5.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.0%	0.4% 1.6 pts worse	1.0% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 3.8% · 4Q avg 2.0% · 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	23.5%	24.2% 0.7 pts better	19.8% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 21.2% · Q3 4.8% · 4Q avg 23.5%
Percentage of long-stay residents with pressure ulcers	4.4%	4.1% 0.3 pts worse	5.1% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 10.0% · Q3 4.1% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.2%	81.6% 12.6 pts better	81.7% 12.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 92.0% · Q4 87.5% · 4Q avg 94.2%
Percentage of short-stay residents who newly received an antipsychotic medication	4.0%	1.3% 2.7 pts worse	1.6% 2.4 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.7%	79.0% 7.7 pts better	79.7% 7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-11 · Fire 2025-06-11

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2024-06-10 · Fire 2024-06-10

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-04-21 · Fire 2023-04-21

3 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-07-10

F · Potential for more than minimal harm 2025-06-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-10

E · Potential for more than minimal harm 2025-06-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-08

E · Potential for more than minimal harm 2025-06-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-07-10

E · Potential for more than minimal harm 2025-06-11

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-07-11

F · Potential for more than minimal harm 2024-06-10

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2024-07-17

F · Potential for more than minimal harm 2024-06-10

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-07-17

F · Potential for more than minimal harm 2024-06-10

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-07-17

E · Potential for more than minimal harm 2024-06-10

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-07-01

E · Potential for more than minimal harm 2024-06-10

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-07-18

E · Potential for more than minimal harm 2024-06-10

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-07-02

E · Potential for more than minimal harm 2024-06-10

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-07-02

E · Potential for more than minimal harm 2024-06-10

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-18

E · Potential for more than minimal harm 2024-06-10

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-07-18

D · Potential for more than minimal harm 2024-06-10

K906 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas cylinders are properly stored.

Corrected 2024-07-18

F · Potential for more than minimal harm 2023-04-21

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2023-06-29

F · Potential for more than minimal harm 2023-04-21

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2023-06-29

F · Potential for more than minimal harm 2023-04-21

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2023-06-29

F · Potential for more than minimal harm 2023-04-21

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-06-29

F · Potential for more than minimal harm 2023-04-21

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-06-29

E · Potential for more than minimal harm 2023-04-21

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-06-29

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-06-11

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 2025-06-27

D · Potential for more than minimal harm 2025-06-11

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-06-27

D · Potential for more than minimal harm 2025-06-11

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-06-27

D · Potential for more than minimal harm 2025-06-11

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-06-27

D · Potential for more than minimal harm 2025-05-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-18

D · Potential for more than minimal harm 2025-04-15

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 2025-05-04

D · Potential for more than minimal harm 2025-04-15

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 2025-05-04

J · Immediate jeopardy 2025-02-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-11-08

D · Potential for more than minimal harm 2025-02-06

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 2025-02-21

F · Potential for more than minimal harm 2024-06-10

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 2024-06-28

E · Potential for more than minimal harm 2024-06-10

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-06-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-10

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-10

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-06-10

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-28

G · Actual harm 2023-05-05

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 2023-04-28

F · Potential for more than minimal harm 2023-04-21

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 2023-05-25

D · Potential for more than minimal harm 2023-04-21

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 2023-05-25

Penalties and ownership