Cycle 1
Health 2025-01-13 · Fire 2025-01-13
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mishawaka, IN
Creekside Village
4-star overall rating with 3-star inspections with 7 recent health deficiencies
1420 E Douglas Rd, Mishawaka, IN
(574) 307-7200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
2010-10-26
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
0.31
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
43%
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
3,860
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.16
Baseline 19.08% · Performance 19.51% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Healthcare-associated infections
6.55
Baseline 6.64% · Performance 5.88% · Measure score 6.55 · Achievement 6.55 · Improvement 4.16
Total nurse turnover
5.06
Baseline 48.68% · Performance 43.01% · Measure score 5.06 · Achievement 5.06 · Improvement 1.88
Adjusted total nurse staffing
1.19
Baseline 3.49 hours · Performance 3.41 hours · Measure score 1.19 · Achievement 1.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 295 · Observed rate 11.19% · Lower 95% interval 7.71% |
| Discharge to community | 64.22% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 258 · Observed rate 57.36% · Lower 95% interval 58.58% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.92% |
95.27%
1.3 pts worse
|
Numerator 170 · Denominator 181 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 181 |
| Discharge self-care score | 32.41% |
53.69%
21.3 pts worse
|
Numerator 47 · Denominator 145 |
| Discharge mobility score | 54.48% |
50.94%
3.5 pts better
|
Numerator 79 · Denominator 145 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 180 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 5.56% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 2.54% |
8.2%
5.7 pts worse
|
Numerator 3 · Denominator 118 |
| Staff flu vaccination coverage | 14.91% |
42%
27.1 pts worse
|
Numerator 17 · Denominator 114 |
| Discharge function score | 58.62% |
56.45%
2.2 pts better
|
Numerator 85 · Denominator 145 |
| Transfer of health information to provider | 98.15% |
95.95%
2.2 pts better
|
Numerator 53 · Denominator 54 |
| Transfer of health information to patient | 96.84% |
96.28%
0.6 pts better
|
Numerator 92 · Denominator 95 |
| Resident COVID-19 vaccinations up to date | 26.25% |
25.2%
1.1 pts better
|
Numerator 21 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
93.6%
0.7 pts better
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 93.2% · Q3 98.2% · Q4 100.0% · 4Q avg 94.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.4%
3.1 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.8%
1.8 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 1.8% · Q4 1.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.5% |
24.6%
9.1 pts better
|
11.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 20.8% · Q3 11.1% · Q4 5.0% · 4Q avg 15.5% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.6%
0.6 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.8% · Q3 0.0% · Q4 1.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
23.5%
14.2 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 11.3% · Q3 10.0% · Q4 10.7% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.2% |
14.8%
13.6 pts better
|
16.7%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · 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 | 13.3% |
13.3%
About the same
|
16.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
11.7%
2.2 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 19.6% · Q3 7.0% · Q4 4.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · 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 urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
24.2%
4.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 21.0% · Q3 21.4% · Q4 12.8% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 9.5% |
4.1%
5.4 pts worse
|
5.1%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 10.1% · Q3 8.7% · Q4 5.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
81.6%
10 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 87.2% · Q3 95.3% · Q4 99.2% · 4Q avg 91.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
10.5%
1.6 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
79.0%
8.2 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
22.4%
0.5 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 21.5% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-21
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 2025-04-10
D · Potential for more than minimal harm
2025-01-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-13
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-13
D · Potential for more than minimal harm
2024-07-02
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 2024-06-24
D · Potential for more than minimal harm
2024-02-09
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 2024-03-10
D · Potential for more than minimal harm
2024-02-09
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 2024-03-10
D · Potential for more than minimal harm
2024-02-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-10
D · Potential for more than minimal harm
2024-02-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-10
D · Potential for more than minimal harm
2024-02-09
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 2024-03-10
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-10
D · Potential for more than minimal harm
2023-10-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-08-18
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 2023-09-09
D · Potential for more than minimal harm
2023-08-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-09-09
G · Actual harm
2022-12-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-12-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-12-02
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 2023-01-05
D · Potential for more than minimal harm
2022-12-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-02
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 2023-01-05
D · Potential for more than minimal harm
2022-12-02
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 2023-01-05
D · Potential for more than minimal harm
2022-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-05
Penalties and ownership
What sits behind the stars
Ownership
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Corporate Officer · Individual
Caine, Virginia
Corporate Officer · Individual
Dice, Mark
Contracted Managing Employee · Individual
Drummer, Carl
Corporate Director · Individual
Ginter, Erin
Operational/Managerial Control · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Officer · Individual
Horn, Brenda
Corporate Director · Individual
Jahangir, Mohammed
Contracted Managing Employee · Individual
Lazard, Robert
Corporate Director · Individual
Mantravadi, Geeta
Corporate Director · Individual
Payne, Monica
Corporate Director · Individual
Singleton, Michelle
Operational/Managerial Control · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
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#2
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2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Holy Cross Rehabilitation And Wellness
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3-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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