Cycle 1
Health 2023-07-12 · Fire 2023-07-12
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Madison, TN
Creekside Center For Rehabilitation And Healing
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
306 W Due West Avenue, Madison, TN
(615) 612-4499
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
139
Certified beds
Average residents
129
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
2014-01-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 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
0.66
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,007
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 18.90% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Healthcare-associated infections
0
Baseline 6.17% · Performance 10.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.75
Baseline 77.99% · Performance 55.40% · Measure score 3.75 · Achievement 2.03 · Improvement 3.75
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.71% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 12.7% · Lower 95% interval 9.32% |
| Discharge to community | 59.66% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 244 · Observed rate 52.87% · Lower 95% interval 54.73% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 228 · Denominator 228 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 228 |
| Discharge self-care score | 59.65% |
53.69%
6 pts better
|
Numerator 102 · Denominator 171 |
| Discharge mobility score | 67.25% |
50.94%
16.3 pts better
|
Numerator 115 · Denominator 171 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 3 · Denominator 228 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 10.33% |
7.12%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 185 · Observed rate 12.43% · Lower 95% interval 7.06% |
| Staff COVID-19 vaccination coverage | 4.06% |
8.2%
4.1 pts worse
|
Numerator 8 · Denominator 197 |
| Staff flu vaccination coverage | 13.5% |
42%
28.5 pts worse
|
Numerator 27 · Denominator 200 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 117 · Denominator 171 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 157 · Denominator 157 |
| Resident COVID-19 vaccinations up to date | 23.39% |
25.2%
1.8 pts worse
|
Numerator 29 · Denominator 124 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.8% |
89.9%
12.1 pts worse
|
93.4%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.0% · Q2 78.0% · Q3 79.7% · Q4 74.4% · 4Q avg 77.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.0% |
94.5%
2.5 pts worse
|
95.5%
3.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.6%
0.5 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 3.8% · Q4 5.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
11.8%
9.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.3% · Q4 2.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.7% · Q3 2.9% · Q4 2.9% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
32.2%
7.3 pts better
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 25.0% · Q3 28.8% · Q4 25.4% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
18.1%
6.9 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.3% · Q3 8.5% · Q4 7.0% · 4Q avg 11.2% · Used in QM five-star |
| 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 · 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 | 3.3% |
19.9%
16.6 pts better
|
16.3%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.4% |
15.3%
14.9 pts better
|
14.9%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 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% |
1.9%
1.9 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 | 18.8% |
20.2%
1.4 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 18.9% · Q3 16.1% · Q4 23.9% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.4%
1.4 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 5.0% · Q3 4.0% · Q4 5.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.8% |
79.6%
10.8 pts worse
|
81.7%
12.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 69.6% · Q3 65.8% · Q4 68.7% · 4Q avg 68.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
11.2%
1 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 11.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.6%
1.2 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.1% |
79.8%
7.7 pts worse
|
79.7%
7.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
22.2%
1 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 21.2% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-01 · Fire 2019-05-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2018-05-16 · Fire 2018-05-16
4 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-07
E · Potential for more than minimal harm
2019-05-01
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-15
D · Potential for more than minimal harm
2019-05-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-05-22
D · Potential for more than minimal harm
2019-05-01
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-07-03
D · Potential for more than minimal harm
2018-05-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-05-28
D · Potential for more than minimal harm
2018-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-28
D · Potential for more than minimal harm
2018-05-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-05-28
D · Potential for more than minimal harm
2018-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-05-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-07-12
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-17
D · Potential for more than minimal harm
2019-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-05-23
D · Potential for more than minimal harm
2018-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-05-16
D · Potential for more than minimal harm
2018-05-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-05-25
D · Potential for more than minimal harm
2018-05-16
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 2018-05-25
D · Potential for more than minimal harm
2018-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-25
Penalties and ownership
What sits behind the stars
Ownership
Madison Ventures Tn LLC
5% Or Greater Direct Ownership Interest · Organization
Md Friedman Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Neal Einhorn Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Zucker, Yossie
5% Or Greater Indirect Ownership Interest · Individual
Couch, James
Operational/Managerial Control · Individual
Friedman, Mark
Corporate Officer · Individual
Rose, Sarah
Operational/Managerial Control · Individual
Salih, Rajin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Old Hickory Village
Old Hickory, TN
3-star overall rating with 2-star inspections with $13,520 in total fines with 12 recent health deficiencies
#2
Alta Heights Post Acute
Goodlettsville, TN
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Whites Creek Wellness And Rehabilitation Center
Whites Creek, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
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