Cycle 1
Health 2026-01-14 · Fire 2026-01-14
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Spencer, IN
Mccormick's Creek Rehabilitation And Healthcare
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
210 State Hwy 43, Spencer, IN
(812) 829-3444
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
87
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Castle Healthcare
Operator or chain grouping
Approved since
1998-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 1 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
0.36
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
2.98
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
2.20
CMS adjusted total nurse staffing hours
Case-mix index
1.85
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,337
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
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
2.44
Baseline 6.78% · Performance 7.10% · Measure score 2.44 · Achievement 2.44 · Improvement 0
Total nurse turnover
7.16
Baseline 59.04% · Performance 34.43% · Measure score 7.16 · Achievement 7.16 · Improvement 6.70
Adjusted total nurse staffing
0.37
Baseline 2.03 hours · Performance 2.36 hours · Measure score 0.37 · Achievement 0 · Improvement 0.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 6.56% |
| Discharge to community | 55.08% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 50% · Lower 95% interval 42.64% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 16 · Denominator 28 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 8 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 0.97% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 103 |
| Staff flu vaccination coverage | 29.21% |
42%
12.8 pts worse
|
Numerator 26 · Denominator 89 |
| Discharge function score | 64.29% |
56.45%
7.8 pts better
|
Numerator 18 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.23% |
25.2%
6 pts worse
|
Numerator 5 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
93.6%
6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.4%
1.8 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.8%
2.2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 4.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 63.0% |
24.6%
38.4 pts worse
|
11.4%
51.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.1% · Q2 63.8% · Q3 64.4% · Q4 70.2% · 4Q avg 63.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.6%
4.3 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.1% |
23.5%
7.6 pts worse
|
19.6%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 29.3% · Q3 31.5% · Q4 36.8% · 4Q avg 31.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
14.8%
2.1 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 15.0% · Q3 11.9% · Q4 13.6% · 4Q avg 12.7% · 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 | 6.4% |
13.3%
6.9 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 14.6% · Q3 8.2% · Q4 4.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.8% |
11.7%
9.9 pts better
|
14.9%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 1.9% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · 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 | 7.5% |
24.2%
16.7 pts better
|
19.8%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 12.1% · Q3 6.6% · Q4 4.7% · 4Q avg 7.5% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.1%
0.8 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.9% · Q3 1.6% · Q4 1.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
81.6%
17.2 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.6% · Q4 98.7% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.0% |
10.5%
11.5 pts worse
|
12.0%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 22.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.4% |
79.0%
14.6 pts worse
|
79.7%
15.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
22.4%
4.8 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.7% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-31 · Fire 2025-01-31
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2024-02-15 · Fire 2024-02-15
4 health deficiencies
Top issue: Environmental (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-03-02
E · Potential for more than minimal harm
2026-01-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-03-02
D · Potential for more than minimal harm
2026-01-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-03-02
F · Potential for more than minimal harm
2025-01-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-18
F · Potential for more than minimal harm
2025-01-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-18
F · Potential for more than minimal harm
2025-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-18
E · Potential for more than minimal harm
2025-01-31
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-01-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-18
F · Potential for more than minimal harm
2024-02-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-18
B · Minimal harm
2024-02-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-14
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 2026-02-04
D · Potential for more than minimal harm
2026-01-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-01-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-03-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-15
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 2024-02-28
D · Potential for more than minimal harm
2024-02-15
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 2024-02-28
D · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-28
Penalties and ownership
What sits behind the stars
Ownership
Major Hospital
5% Or Greater Direct Ownership Interest · Organization
Berdugo, Shai
Operational/Managerial Control · Individual
Claxton, Ryan
Corporate Officer · Individual
Hughes, Edward
Operational/Managerial Control · Individual
Spencer Realty LLC
5% Or Greater Mortgage Interest · Organization
Spencer Rehabilitation And Healthcare Center LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Owen Valley Rehabilitation And Healthcare Center
Spencer, IN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Richland Bean Blossom Health Care Center
Ellettsville, IN
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Stonecroft Health Campus
Bloomington, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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