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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 37th out of 267 homes in Indiana.| Staff type | Hours / day | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 30m per day | ▼ 32% State avg: 44m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 47m per day | ■ Avg State avg: 47m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 7m per day | ▼ 9% State avg: 2h 20m per day · National avg: 2h 20m per day |
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 40m per day | ▲ 4% State avg: 3h 31m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 4m per day | ▼ 20% State avg: 5m per day · National avg: 4m per day |
|
RN (Weekend)
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 23m per day | ▼ 28% State avg: 32m per day · National avg: 28m per day |
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
23% of new residents, usually for short-term rehab.
77% of new residents, often for short stays.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #39 / 267Payroll — state benchmarkedThis home is ranked 39th out of 267 homes in Indiana.Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Higher than the Indiana average: 68.1%Creekside Health and Rehabilitation Center is legally operated by Riverview Hospital, and administrated by Stacia Dawson.
Key information about the people who lead and staff this community.
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies are formal regulatory issues recorded during state inspections.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 44 | 36 | This facility has 22% more total deficiencies than a typical Indiana nursing home (44 vs. IN avg 36).↑ 22% worse |
|
Deficiencies per year
Average deficiencies per year since 2022.
| 11 | 9 | This facility has 22% more deficiencies per year than a typical Indiana nursing home (11 vs. IN avg 9).↑ 22% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 1.5 | 1.9 | This facility has 21% fewer deficiencies per inspection than a typical Indiana nursing home (1.5 vs. IN avg 1.9).↓ 21% better |
State inspections evaluate whether the facility meets health and safety standards.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 29 | 19 | This facility has 53% more total visits than a typical Indiana nursing home (29 vs. IN avg 19).↑ 53% worse |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 10 | 7 | This facility has 43% more inspections with deficiencies than a typical Indiana nursing home (10 vs. IN avg 7).↑ 43% worse |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 34% | 37% | This facility has 3 percentage points lower inspection deficiency rate than a typical Indiana nursing home (34% vs. IN avg 37%).↓ 3% better |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 24 | 13 | This facility has 85% more inspections than a typical Indiana nursing home (24 vs. IN avg 13).↑ 85% worse |
Complaints are formal concerns filed by residents, families, or staff. Investigations are on-site follow-ups.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 8 | 5 | This facility has 60% more total complaints than a typical Indiana nursing home (8 vs. IN avg 5).↑ 60% worse |
|
Complaints per year
Average complaints per year since 2022.
| 2 | 1.3 | This facility has 54% more complaints per year than a typical Indiana nursing home (2 vs. IN avg 1.3).↑ 54% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on June 16, 2025, found the facility in compliance with no deficiencies cited during the paper review of two complaint investigations. Earlier inspections showed a pattern of deficiencies primarily related to care planning, communication with residents’ representatives, and timely notification of medication changes and hospital transfers. Prior reports also noted issues with resident dignity, assistance with activities of daily living, and coordination of specialized care such as dialysis and mental health services. Complaint investigations were mostly unsubstantiated, with substantiated complaints generally involving care coordination and documentation. The facility appears to be improving over time, with recent inspections showing corrections of earlier deficiencies and no enforcement actions or fines listed in the available reports.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Aug 2025
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
30 of 40 citations resulted from standard inspections; 6 of 40 resulted from complaint investigations; and 4 of 40 came from combined inspections (standard and complaint).
100% better than Indiana averageIndiana average: 0.2
2
233% worse than Indiana averageIndiana average: 0.6
Issues related to resident's rights, including dignity, privacy, and the ability to make decisions about their care.
Aug 22, 2025
Corrected
Issues related to resident's rights, including dignity, privacy, and the ability to make decisions about their care.
May 28, 2025
Corrected
Issues related to resident's rights, including dignity, privacy, and the ability to make decisions about their care.
May 28, 2025
Corrected
Issues related to creating and updating personalized care plans for residents based on their needs and conditions.
Mar 12, 2025
Corrected
Data sourced from CMS Health Deficiencies reports. Citation severity codes range from A (least serious) to L (most serious). Immediate Jeopardy (J-L) citations indicate situations where the facility's noncompliance has placed residents at risk of death or serious harm.
Creekside Health and Rehabilitation Center is located in INDIANAPOLIS, Indiana.
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3.9 miles from city center
Estimated distance in miles from Indianapolis's city center to Creekside Health and Rehabilitation Center's address, calculated via Google Maps.
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This data corresponds to Q2 2025 and is based on CMS Payroll-Based Journal.
1770542% better than Indiana averageIndiana average ratio: 0.00:1
0% compared with Indiana averageIndiana average: 7.7 hours
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.4 hoursNo contractors work on this role.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.4 hoursNo contractors work on this role.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hoursThis role is partially covered by contractors.
Total hours from contractors
3,980 contractor hours this quarter
| Certified Nursing Assistant | 91 | 1 | 92 | 21,490 | 91 | 100% | 7.6 |
| Licensed Practical Nurse | 20 | 0 | 20 | 7,152 | 91 | 100% | 8.4 |
| Medication Aide/Technician | 19 | 0 | 19 | 7,126 | 91 | 100% | 9.5 |
| Other Dietary Services Staff | 9 | 0 | 9 | 3,146 | 89 | 98% | 6.7 |
| Registered Nurse | 13 | 0 | 13 | 3,053 | 91 | 100% | 7.4 |
| RN Director of Nursing | 6 | 0 | 6 | 2,525 | 78 | 86% | 8.2 |
| Dental Services Staff | 5 | 0 | 5 | 2,352 | 65 | 71% | 8 |
| Respiratory Therapy Technician | 0 | 5 | 5 | 1,421 | 75 | 82% | 7 |
| Clinical Nurse Specialist | 4 | 0 | 4 | 1,081 | 65 | 71% | 6.2 |
| Qualified Social Worker | 0 | 5 | 5 | 633 | 68 | 75% | 5.9 |
| Physical Therapy Assistant | 0 | 6 | 6 | 612 | 83 | 91% | 6.5 |
| Speech Language Pathologist | 0 | 2 | 2 | 561 | 70 | 77% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 520 | 65 | 71% | 8 |
| Administrator | 1 | 0 | 1 | 488 | 61 | 67% | 8 |
| Physical Therapy Aide | 0 | 2 | 2 | 470 | 59 | 65% | 7.8 |
| Qualified Activities Professional | 0 | 2 | 2 | 282 | 46 | 51% | 5.5 |
| Occupational Therapy Aide | 1 | 0 | 1 | 11 | 4 | 4% | 2.8 |
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
109Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
7.7
In line with Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
20.5
20% worse than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
8.6%
28% better than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
19.7%
37% worse than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
33.2%
35% worse than Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
0.3%
93% better than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
2.0%
54% better than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
0.5%
56% better than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
7.8%
37% worse than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
4.1%
83% better than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
5.4%
57% better than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
88.7%
5% worse than Indiana averageIndiana average: 93.7%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
92.0%
In line with Indiana averageIndiana average: 95.4%
Number of hospitalizations per 1,000 long-stay resident days.
1.59
24% better than Indiana averageIndiana average: 2.10
Number of outpatient emergency department visits per 1,000 long-stay resident days.
0.25
79% better than Indiana averageIndiana average: 1.18
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
77.9%
5% worse than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
2.2%
57% worse than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
90.5%
15% better than Indiana averageIndiana average: 79.0%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
25.3%
In line with Indiana averageIndiana average: 26.2%
Percentage of short-stay residents who had an outpatient emergency department visit.
8.6%
8% better than Indiana averageIndiana average: 9.3%
Percentage of SNF residents who experience falls with major injury during their stay.
1.3%
69% worse than Indiana averageIndiana average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
42.3%
21% worse than Indiana averageIndiana average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
40.8%
19% worse than Indiana averageIndiana average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
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NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
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| Creekside Health and Rehabilitation Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Indianapolis (Mapleton - Fall Creek) | 120 | 95.8% | +38% | 4.22 | -29% | +23% | 0 | 40 | 5.7 | 2 | 106 | - | 58 | Creekside Rehab Holdings, LLC | $19.8M | $6.7M | 33.7% | 155628 | ||||
| American Village |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
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| Alpha Home – a Waters Community |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
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Historical financial and operational data for Creekside Health and Rehabilitation Center based on CMS SNF Cost Reports.
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Creekside Health and Rehabilitation Center is in the Mapleton - Fall Creek neighborhood of INDIANAPOLIS.
Ladonna Lewis is the Director of Nursing at Creekside Health and Rehabilitation Center.
The legal owner and operator of Creekside Health and Rehabilitation Center is Riverview Hospital.
Creekside Health and Rehabilitation Center has a walk score of 58. Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.
According to IN state health department records, Creekside Health and Rehabilitation Center's license number is 24-009569-1.
According to IN state health department records, Creekside Health and Rehabilitation Center's license expires on July 31, 2025.
Creekside Health and Rehabilitation Center's occupancy is 91%.
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