Cycle 1
Health 2025-12-03 · Fire 2025-12-03
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Creighton, NE
Avera Creighton Care Centre
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1603 Main Street, Creighton, NE
(402) 358-5701
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
2010-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 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
1.81
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.85
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
1.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.99
CMS adjusted RN staffing hours
Adjusted total hours
5.34
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,475
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0116
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.46
Baseline 45.83% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 0
Adjusted total nurse staffing
6.83
Baseline 3.85 hours · Performance 5.02 hours · Measure score 6.83 · Achievement 6.83 · Improvement 5.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.8% |
8.2%
5.4 pts worse
|
Numerator 3 · Denominator 107 |
| Staff flu vaccination coverage | 71.43% |
42%
29.4 pts better
|
Numerator 50 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.0
1.1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
92.8%
6.5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 14.2% |
4.5%
9.7 pts worse
|
3.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.3% · Q3 17.1% · Q4 15.8% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 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 who lose too much weight | 2.3% |
5.3%
3 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 5.7% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.8% |
19.5%
11.3 pts worse
|
19.6%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 25.8% · Q3 31.4% · Q4 30.3% · 4Q avg 30.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
21.6%
11 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 7.4% · Q3 15.6% · Q4 7.4% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 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 | 22.8% |
20.4%
2.4 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
19.9%
0.2 pts better
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 25.8% · Q3 20.6% · Q4 15.2% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.6%
1.8 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 2.8% · Q3 3.2% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.9%
About the same
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
26.6%
7.1 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 8.4% · Q3 17.5% · Q4 21.4% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.3%
2.5 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 3.2% · Q3 9.8% · Q4 5.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.5%
19.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
75.9%
19.6 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-24 · Fire 2024-09-24
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-09-05 · Fire 2023-09-05
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-30
F · Potential for more than minimal harm
2024-09-24
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-08
F · Potential for more than minimal harm
2023-09-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-19
F · Potential for more than minimal harm
2023-09-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-12-03
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 2025-12-17
D · Potential for more than minimal harm
2025-12-03
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 2026-01-02
D · Potential for more than minimal harm
2025-12-03
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-01-30
F · Potential for more than minimal harm
2024-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-24
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 2024-10-09
F · Potential for more than minimal harm
2023-09-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-05
E · Potential for more than minimal harm
2023-09-05
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-05
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-05
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 2023-10-05
D · Potential for more than minimal harm
2023-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-05
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Becker, Carolyn
Corporate Director · Individual
Ekeren, Douglas
Operational/Managerial Control · Individual
Ekeren, Douglas
Corporate Director · Individual
Greeneway, Kathy
Corporate Director · Individual
Hiltunen, Scott
Corporate Director · Individual
Hunhoff, Bernie
Corporate Director · Individual
Hurley, John
Corporate Director · Individual
Kolecka, Debra
Corporate Director · Individual
Laflan, Douglas
Contracted Managing Employee · Individual
Leon, Amy
Corporate Director · Individual
Lorang, Thomas
Corporate Director · Individual
Mikkelsen, Beth
Corporate Director · Individual
Schindler, Steve
Corporate Director · Individual
Schmeichel, Steve
Corporate Director · Individual
Seifert, Roxanne
Corporate Director · Individual
Steward, Brian
Corporate Director · Individual
Strom, Richard
Corporate Director · Individual
Sutton, Bobby
Corporate Director · Individual
Welbig, Lucille
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Plainview Manor
Plainview, NE
4-star overall rating with 3-star inspections with 10 recent health deficiencies
#2
Alpine Village Retirement Center
Verdigre, NE
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Bloomfield
Bloomfield, NE
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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