Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Hickory Creek At Rochester during CMS and state inspections, most recent first.
A resident with multiple comorbidities was transported in a facility bus without a seat belt after complaining of pain at a surgical site. The wheelchair was secured, but the seat belt was not used, contrary to facility policy. When the driver braked suddenly, the resident slid out of the wheelchair, sustaining abrasions and a hematoma.
A facility did not report an allegation of misappropriation of a resident's antibiotic medication to the state agency after an internal investigation found that the medication had been signed out and administered as ordered. The incident was not reported despite facility policy requiring such allegations, including missing prescription medications, to be reported to authorities.
A resident with multiple medical conditions was prescribed an antibiotic for a wound infection, but after being hospitalized, the facility failed to complete and document the required medication destruction form for the remaining doses. Staff interviews and record reviews confirmed the absence of both the medication and the necessary documentation, in violation of facility policy.
A resident with a history of paraplegia and muscle wasting was admitted with a Stage 2 pressure ulcer, which worsened to Stage 4 due to the facility's failure to notify the physician and obtain timely treatment orders. The resident developed additional pressure ulcers, requiring treatment at a wound care center and a surgical colostomy. Facility staff did not follow policies for notifying physicians of changes in condition, leading to a delay in care.
A facility failed to notify a resident's POA or family about the presence and worsening of pressure ulcers and multiple roommate changes. The resident, admitted with a stage 2 pressure ulcer and other serious conditions, had no documented notification to the family despite facility policy requiring such communication.
The facility was found to have broken seals on the freezer and refrigerator doors during a kitchen tour. The Dietary Manager confirmed the need for repairs. The facility's policy requires reporting defective equipment and routine maintenance, but these issues were not addressed.
The facility failed to conduct annual performance evaluations for four CNAs, as revealed through staff interviews and file reviews. CNA 3 and CNA 4 reported not receiving evaluations, and the Business Office Manager confirmed that evaluations were not conducted after a company takeover. The Administrator admitted that evaluations should be done annually but were not completed due to high turnover, and there was no policy in place for performance evaluations.
The facility failed to implement proper infection control practices, including Enhanced Barrier Precautions for a dialysis resident, improper blood sugar check procedures by a QMA, and inadequate catheter care by a CNA. Additionally, a resident's catheter tubing was repeatedly observed on the floor, indicating lapses in protocol adherence.
The facility failed to provide transfer/discharge forms for two residents who were hospitalized. One resident with sepsis and Alzheimer's was transferred without the necessary documentation, and another with a hip fracture and stroke history was sent to the ER without the required form. The DON confirmed the oversight.
The facility failed to provide the bed hold policy to two residents during hospital transfers. One resident with sepsis, Alzheimer's, and cerebral infarction, and another with a femur fracture and stroke-related conditions, were not given the policy as required. The DON confirmed the policy should be documented in the Hospital-ER Transfer Form, but it was missing in both cases.
A resident with multiple health issues had a non-healing wound on her lower back that was not properly managed by the facility. Despite signs of infection and the wound's worsening condition, the physician was not notified for a new treatment plan. The facility's failure to communicate changes in the wound's condition led to a deficiency.
A facility failed to properly store a Bi-Pap mask for a resident with pulmonary hypertension, COPD, and obstructive sleep apnea. The mask was found on the floor under the bed, contrary to the physician's order and care plan, which did not address Bi-Pap use. The facility's policy lacked guidance on mask storage, and the DON stated it should be stored in a respiratory bag.
Failure to Use Seat Belt During Resident Transport Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident was transported back to the facility after a hospital visit for a suprapubic catheter placement. The staff member responsible for transportation secured the resident's wheelchair to the bus floor but did not fasten the seat belt because the resident complained of pain at the abdominal incision site. Despite the facility's policy requiring seat belts for all passengers, the seat belt was not used. During the return trip, the driver had to brake suddenly for a stopped school bus, causing the resident to lean forward, hit her forehead and face on the seat in front, and slide out of her wheelchair onto the floor. The resident, who had diagnoses including diabetes, obesity, hypertension, anxiety, and depression, required assistance for ambulation and transfers according to her MDS assessment. After the incident, she was found to have an abrasion on her lower back, a pink abrasion on her left knee, and a hematoma on her forehead. The event was witnessed and documented in the nursing progress notes, and the facility's transportation policy requiring seat belt use was not followed during this incident.
Failure to Report Alleged Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the appropriate state agency for one resident. A nurse reported to the Regional Director of Clinical Services (RDCS) that another nurse may have taken antibiotic medications from the medication room. The RDCS conducted an investigation and determined that the antibiotic medication in question had been signed out and administered to the resident as ordered, with no confirmed misappropriation. As a result, the Administrator did not report the allegation to the state agency. The RDCS also indicated that no other residents on antibiotics were investigated, as the description of the medication container provided by the reporting nurse only matched the medications for the resident in question. The facility's policy requires that all incidents of misappropriation of resident property, including missing prescription medications, be reported to the Indiana Department of Health in compliance with federal and state regulations. Despite this policy, the allegation was not reported because the internal investigation did not confirm misappropriation.
Failure to Document Medication Destruction for Hospitalized Resident
Penalty
Summary
The facility failed to ensure proper documentation and completion of a medication destruction form for a resident who was hospitalized. The resident, who had diagnoses including paraplegia, psychosis, hypertension, and spinal fusion, was prescribed Augmentin for a wound infection. The medication was started and administered for several days, but after the resident was admitted to the hospital, there were six remaining tablets that were not accounted for. The resident's record did not contain documentation of a Drug Disposition form for the remaining medication. Interviews with nursing staff and review of the medication cart confirmed that the required drug destruction documentation was missing, and the remaining medication was not found in the cart. The facility's policy required discontinued medications to be destroyed or returned to the pharmacy and documented accordingly, but no such documentation was present for this resident's unused antibiotics.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent the worsening of a pressure ulcer for a resident, leading to the deterioration of an existing pressure ulcer from Stage 2 to Stage 4 and the development of multiple new pressure ulcers. Upon admission, the resident had a pressure ulcer on the coccyx, but the facility did not notify the physician or obtain immediate treatment orders, placing the resident in immediate jeopardy of serious harm. The resident's clinical record indicated a history of conditions such as paraplegia, muscle wasting, and chronic ulcers, which increased the risk for pressure ulcer development. The resident's care plan and assessments highlighted the need for assistance with activities of daily living and the use of pressure-reducing devices. Despite these measures, the facility's documentation showed a lack of timely physician notification and specific treatment orders for the pressure ulcers. Progress notes revealed that the resident's wounds were not adequately monitored or treated, and the physician was not informed of the resident's condition until several weeks after admission. This delay in care contributed to the worsening of the resident's pressure ulcers and the need for treatment at a local wound care center. Interviews with facility staff, including the Medical Director and Assistant Director of Nursing, confirmed the lack of timely communication and intervention for the resident's pressure ulcers. The Medical Director stated that he was not made aware of the resident's condition until weeks after admission, and the Assistant Director of Nursing admitted to not documenting communication with the physician. The facility's policies on resident change of condition and skin management were not followed, resulting in the resident's pressure ulcers progressing to a severe state requiring surgical intervention.
Failure to Notify Resident's Family of Condition and Room Changes
Penalty
Summary
The facility failed to notify a resident's responsible party in a timely manner regarding changes in the resident's condition and room assignments. Specifically, the facility did not inform the Power of Attorney (POA) or family member of Resident B about the presence and worsening of pressure ulcers upon admission and the development of additional pressure ulcers. Furthermore, the facility did not notify the POA or family member about multiple roommate changes that occurred on several occasions. Resident B, who was admitted from an acute care facility, had a range of diagnoses including non-pressure chronic ulcer, paraplegia, and other serious conditions. Upon admission, Resident B had a stage 2 pressure ulcer, which was documented in various nursing progress notes without evidence of notification to the POA or family. The facility's policy required communication of changes in resident condition to the physician and family/responsible party, which was not adhered to in this case.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment in good working condition, as observed during a kitchen tour with the Dietary Manager. The inspection revealed broken seals on both doors of the freezer and on two refrigerators. During an interview, the Dietary Manager acknowledged that the seals needed to be fixed. The facility's policy, titled 'Kitchen Safety Guidelines' and dated April 2024, was provided by the Regional Nurse Consultant. This policy requires all employees to report defective equipment and mandates the maintenance department to conduct routine inspections and repairs of equipment.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for four certified nursing assistants (CNAs) whose files were reviewed. Interviews with staff members, including CNA 3 and CNA 4, revealed that the facility did not conduct annual competencies or evaluations. CNA 3 mentioned that evaluations were not done every year, while CNA 4 stated she had not received a performance evaluation since her employment began. The Business Office Manager confirmed that evaluations were not conducted after a new company took over, although raises were given in January. The Administrator acknowledged that evaluations should be done annually and admitted that due to high turnover, not all evaluations were completed. The employee files for CNAs 3, 4, 7, and 8 were reviewed, and none contained annual performance evaluations. CNA 3 was hired in February 2023, CNA 4 in April 2023, CNA 7 in August 2017, and CNA 8 in September 2019. The Business Office Manager reiterated that evaluations should occur annually, and the Administrator confirmed the absence of a policy regarding performance evaluations. This lack of adherence to annual performance evaluations represents a deficiency in the facility's management of staff performance and competency assessments.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices for Enhanced Barrier Precautions (EBP) for a resident undergoing dialysis. Despite the resident having a right jugular perma catheter and being at risk for infection, there was no signage or indication of EBP isolation. Interviews with staff revealed a lack of awareness regarding the resident's need for EBP, indicating a gap in communication and protocol adherence. During a blood sugar check, a Qualified Medication Aide (QMA) did not follow proper infection control procedures. The QMA placed the glucometer on a bedside table without a barrier, fanned the cleansed area of the resident's finger, and exited the room with gloves on, which were only removed at the medication cart. This sequence of actions demonstrated a failure to maintain sterile technique and proper hand hygiene. In another instance, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene during catheter care for a resident with multiple catheters. The CNA used the same gloves to perform various tasks after completing peri and catheter care. Additionally, a resident's urinary catheter tubing was repeatedly observed on the floor, contrary to facility policy. These observations highlight lapses in infection control practices and adherence to established protocols.
Failure to Provide Transfer/Discharge Forms for Hospitalized Residents
Penalty
Summary
The facility failed to provide a transfer/discharge form for two residents who were hospitalized. For Resident 11, who had diagnoses including sepsis, Alzheimer's disease, and cerebral infarction, the deficiency was identified during a record review. On a specific date, Resident 11 refused to eat or drink, prompting the physician to be notified. The resident's Power of Attorney requested hospitalization. However, the required Hospital-ER Transfer Form was not found in the electronic medical record, indicating a failure to complete the necessary documentation for the transfer. Similarly, for Resident 1, who had a nondisplaced intertrochanteric fracture of the right femur, hemiplegia, hemiparesis following a stroke, and osteoporosis, the facility did not provide the necessary transfer/discharge form. After a fall that resulted in hip and back pain, the physician ordered the resident to be sent to the emergency department. Although a Hospital-ER Transfer Form was dated and noted, it was found that the resident or their representative was not provided with the transfer/discharge form. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the form should have been completed.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide the bed hold policy to two residents who were transferred to the hospital, resulting in a deficiency. For Resident 11, who had diagnoses including sepsis, Alzheimer's disease, and cerebral infarction, the bed hold policy was not documented in the electronic medical record when the resident was transferred to the hospital. The Director of Nursing (DON) indicated that the bed hold policy should be part of the Hospital-ER Transfer Form under the Observation tab, but this form could not be found for Resident 11. Similarly, for Resident 1, who had a nondisplaced intertrochanteric fracture of the right femur, hemiplegia, hemiparesis following a stroke, and osteoporosis, the bed hold policy was not provided to the resident or their representative upon transfer to the hospital. The DON confirmed that the policy should be completed when a resident is transferred or discharged, but the Hospital-ER Transfer Form did not include a copy of the bed hold policy for Resident 1. The facility's policy requires that residents and their representatives be informed of the bed hold policy at the time of transfer, which was not adhered to in these cases.
Failure to Notify Physician of Non-Healing Wound
Penalty
Summary
The facility failed to notify the physician of a non-healing wound with eschar for a resident with multiple diagnoses, including diabetes and intellectual disabilities. The resident had a wound on her lower back that was not healing and showed signs of infection. Despite the presence of bloody drainage and the wound's worsening condition, the physician was not informed of the need for a new treatment plan. Observations revealed that the dressing was not adhering properly, and the wound was exposed to friction from the resident's chair, exacerbating the condition. The resident's care plan and progress notes indicated ongoing issues with the wound, including slough and purulent drainage. The resident continued to pick at the wound, which contributed to its deterioration. Despite these observations, the facility did not communicate the changes in the wound's condition to the physician, as required by their policy. This lack of communication and failure to update the treatment plan led to the deficiency identified by the surveyors.
Improper Storage of Bi-Pap Mask
Penalty
Summary
The facility failed to properly store a Bi-Pap mask for a resident with pulmonary hypertension, COPD, and obstructive sleep apnea. During an observation, the Bi-Pap mask was found on the floor under the bed, which was not in accordance with the physician's order for its use at bedtime and removal upon waking. The resident's care plan, which addressed potential impaired gas exchange, did not include instructions for the use of the Bi-Pap. Additionally, the facility's policy on Bi-Level Therapy did not provide guidance on the storage of the mask when not in use. The Director of Nursing indicated that the mask should be stored in a respiratory bag when not in use.
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 189 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 Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Rochester | 0.8 mi | ★★★★★ | 18 | 0 |
| Miller's Merry Manor | 16 mi | ★★★★★ | 15 | 0 |
| Miller's Merry Manor | 19.8 mi | ★★★★★ | 0 | 0 |
| Hickory Creek At Winamac | 20.4 mi | ★★★★★ | 7 | 0 |
| Pulaski Health Care Center | 20.4 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hickory Creek At Rochester.
100% money-back within 48 hours.
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.