Cycle 1
Health 2025-01-15 · Fire 2025-01-15
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Indianapolis, IN
Creekside Health And Rehabilitation Center
3-star overall rating with 2-star inspections with 10 recent health deficiencies
3114 East 46th Street, Indianapolis, IN
(317) 920-7888
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
1997-07-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 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
0.54
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,194
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.97% · Performance 22.28% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.63
Baseline 5.09% · Performance 7.05% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Total nurse turnover
2.85
Baseline 66.88% · Performance 52.80% · Measure score 2.85 · Achievement 2.66 · Improvement 2.85
Adjusted total nurse staffing
2.99
Baseline 3.62 hours · Performance 3.93 hours · Measure score 2.99 · Achievement 2.99 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 10.08% · Lower 95% interval 6.71% |
| Discharge to community | 52.83% |
50.57%
2.3 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 43.36% · Lower 95% interval 43.82% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 60 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 20 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 3 · Denominator 60 · Adjusted rate 5.06% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 8.11% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 0.95% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 211 |
| Staff flu vaccination coverage | 32.02% |
42%
10 pts worse
|
Numerator 73 · Denominator 228 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 22 · Denominator 42 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.43% |
25.2%
6.2 pts better
|
Numerator 11 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
93.6%
2.9 pts worse
|
93.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 88.0% · Q3 88.8% · Q4 93.5% · 4Q avg 90.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.0% |
95.4%
3.4 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 | 0.5% |
3.8%
3.3 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
24.6%
19 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.5% · Q3 0.0% · Q4 12.2% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.6%
1.7 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 5.6% · Q3 5.9% · Q4 6.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
23.5%
12 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.2% · Q3 12.9% · Q4 13.5% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
14.8%
5.2 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.8% · Q3 10.3% · Q4 11.4% · 4Q avg 9.6% · 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 | 20.6% |
13.3%
7.3 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 17.2% · Q3 4.1% · Q4 4.3% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
11.7%
4.1 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 6.3% · Q3 2.7% · Q4 0.0% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.4%
1.3 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 2.6% · Q4 1.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
24.2%
6.9 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 41.5% · Q3 32.0% · Q4 19.3% · 4Q avg 31.1% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.1%
2.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.1% · Q3 1.9% · Q4 1.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.5% |
81.6%
2.9 pts better
|
81.7%
2.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.2% · Q2 79.1% · Q3 89.5% · Q4 94.0% · 4Q avg 84.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
10.5%
5.7 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 16.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
79.0%
11.5 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
22.4%
6.9 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 16.7% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-05 · Fire 2023-12-05
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-09 · Fire 2022-08-09
22 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-12-05
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-08-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-28
D · Potential for more than minimal harm
2022-08-09
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 2022-09-28
B · Minimal harm
2022-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-05-28
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 2025-06-12
D · Potential for more than minimal harm
2025-05-28
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-03-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-25
G · Actual harm
2025-01-15
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 2025-02-08
E · Potential for more than minimal harm
2025-01-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-08
D · Potential for more than minimal harm
2025-01-15
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 2025-02-08
D · Potential for more than minimal harm
2025-01-15
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 2025-02-08
D · Potential for more than minimal harm
2025-01-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-08
E · Potential for more than minimal harm
2023-12-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-12-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-12-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-05
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 2023-12-29
D · Potential for more than minimal harm
2023-03-14
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-04-05
G · Actual harm
2022-08-09
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-09-07
F · Potential for more than minimal harm
2022-08-09
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-07
E · Potential for more than minimal harm
2022-08-09
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 2022-09-07
E · Potential for more than minimal harm
2022-08-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
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 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
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 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
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 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-09-07
C · Minimal harm
2022-08-09
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Briarwood Healthcare Operations Company, LLC
Operational/Managerial Control · Organization
Dawson, Stacia
Operational/Managerial Control · Individual
Friend, Jayna
Corporate Officer · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Yassin Kassab, Mahmoud
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
American Village
Indianapolis, IN
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Community Nursing And Rehabilitation Center
Indianapolis, IN
2-star overall rating with 1-star inspections with Special Focus status with 24 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
North Capitol Nursing & Rehabilitation Center
Indianapolis, IN
2-star overall rating with 2-star inspections with 9 recent health deficiencies
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