Avera Creighton Care Centre
1603 Main Street, Creighton, NE 68729 · Non profit - Corporation · 47 certified beds · (402) 358-5701 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0606), cited Sep 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.3% | 19.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 1.4% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 12.8% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.6% | 18.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 28.5% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.0% | 25.9% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.5% | 20.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 75.9% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.54 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.46 | 1.92 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 47 beds and averages 38.6 residents a day — about 82% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 4.05 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.34 to 0.95 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · Ecited before2025-12-03 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B)(D) Based on observation, record review and interview; the facility failed to complete hand hygiene at appropriate intervals to prevent potential infection/cross contamination during the provision of cares for Resident 1, 3, 12, 20, 28 and 36. The total sample size was 12 and the facility census was 37. Findings are:A. Review of the facility policy Hand Hygiene with a revision date of 11/20/25 revealed the facility considered Hand Hygiene to be the primary means of preventing the transmission of infection. -Hand hygiene with either soap and water or Alcohol Based Hand Sanitation (ABHR) was to be completed before touching a resident, before a clean procedure or handling an invasive medical device, after contact with potential for body fluid or contaminated surfaces, after touching a resident or the resident's immediate environment, and after removing gloves. B. Review of the facility policy General Standard Precautions with a revision date of 5/2023 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-03 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to ensure Resident 2's Post Traumatic Stress Disorder (PTSD-a mental health condition caused by extremely stressful or terrifying events. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrolled thoughts) triggers and interventions to address triggers were identified in the resident care plan. The total sample size was 18 and the facility census was 37. Findings are: Review of Resident 2's Minimum Data Set (MDS- federally mandated assessment used in the development of resident care plans) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of anxiety, depression, lung disease, and heart failure. The following was assessed regarding Resident 2:-cognitively intact but had episodes of disorganized thinking. -behaviors which included delusions, resistance with cares and verbal behaviors directed at others. -current medications included an antidepressant, anticonvulsant (used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)Based on observation, record review, and interview; the facility failed to implement assessed interventions to prevent a potential injury from a hot liquid spill for Resident 32. The facility census was 37 and the sample size was 1.Findings are:A. Review of the facility policy Hot Liquids Assessment and Spill Occurrences with a revision date of 11/2025 revealed all residents were to be assessed for risk of injury from consuming hot liquids, including physical capabilities and contributing factors. Residents were to be identified utilizing a Hot Liquid Risk Assessment tool. The assessment was to be completed on admission, annually, with significant changes and with any hot liquid spill. Residents considered at risk or that had a score of 6-9 on the assessment were to wear one lap cover and one apron (one over their lap and one on their chest) and will have an orange name tag on their dining room table. Risk for hot liquids and interventions used were to be included…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-03 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(vi)Based on record review and interview; the facility to ensure residents received trauma informed care related to diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition caused by extremely stressful or terrifying events. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrolled thoughts) and to identify potential triggers as well as resident preferences to prevent and/or mitigate re-traumatization for 1 (Resident 2) of 1 sampled resident. The facility census was 37. Findings include:Review of Resident 2's Minimum Data Set (MDS- federally mandated assessment used in the development of resident care plans) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of anxiety, depression, lung disease, and heart failure. The following was assessed regarding Resident 2:-cognitively intact but had episodes of disorganized thinking. -behaviors which included delusions, resistance with cares and verbal behaviors…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-24 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to perform hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) at the required intervals and to utilize the required personal protective equipment (PPE-can include items such as gowns, gloves, masks, goggles and/or face shields) during the provision of room tray meal service to prevent the potential spread of COVID-19. This practice had the potential to affect all facility residents. The total sample size was 17 and the facility census was 34. Findings are: A. Record review of the facility policy Transmission-Based Precautions (Isolation) with a revision date of 10/25/23 revealed residents who had been placed on Airborne Respirator Precautions and Contact Precautions required use of the following PPE before entering the resident's room: -fit tested N95 mask (a respiratory protective device designed to achieve a very close facial fitting and very efficient filtration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-24 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.12(D)(i)(2) Based on observation, record review and interview; the facility failed to account for narcotic medications according to the facility policy. This had the potential to affect Residents 6, 26, 3, 21, 8 and 17. The total sample size was 13 and the facility census was 34. Findings are: Review of the facility policy Long Term Care Controlled Substances with a revision date of 7/24 revealed the following: -all scheduled controlled medications were to be kept in double locked locations on the medication cart with a controlled substance record (form used to document the time a narcotic medication was administered, the number of pills remaining and the staff's initials) to be stored on each cart. -the controlled substance record was to identify a resident's name, room number, their physician, and the medication order including strength and the route used for administration of the medication. Observation of a medication pass on 9/19/24 at 12:05 PM revealed the following: -Registered Nurse (RN)-K administered one tablet of Oxycodone/APAP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to ensure hair was restrained with a hair net, proper hand hygiene was followed and that utensils were handled to prevent potential food contamination during the food service. These practices had the potential to affect all residents. The sample size was 13 and the facility census was 41. Findings are: Review of the facility policy Infection Prevention in Food Safety/Sanitation Program for Nutrition Services with a revision date of 7/23 revealed the following: -hair restraints would be worn by all personnel preparing or serving food, -personnel must wash hands with soap and water before handling food and dishes, or after touching face, touching hair or combing hair, -disposable gloves would be worn when handling food with hands to ensure bacteria are not transferred from the food handlers' hands to the food product being served. Gloves are just like hands. Anytime a contaminated surface would be touched, the gloves need to be changed-washing hands after removing the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-05 · tag F0728 — failed to protect against nurse-aide misconduct — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04A1 Based on record review and interview, the facility failed to ensure 3 nurse aides (NA-F, NA-P, and NA-Q) were certified through the Nebraska board of nursing prior to working with residents. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility's job description for a Certified Nursing Assistant (CNA) revealed nurse aides were required to be certified through the Nebraska board of nursing within 120 days of being hired. B. Review of a hand written document provided by the Director of Nurses (DON), revealed NA-F worked in the facility as a nurse aide on the following dates: -August 2022 (5th, 6th, 8th, 12th, 17th, 23rd, 25th, 26th, 29th, and 31st); -September 2022 (1st, 9th, 10th, 12th, 15th, 22nd, 26th, 28th, and 29th); -October 2022 (4th, 6th, 13th, 14th, 20th, 22nd, 26th, and 27th); -November 2022 (5th, 6th, 15th, and 18th); -December 4, 2022; and -January 2023 (16th, 19th, 20th and 27th) Further review of hand written documents provided by the DON, revealed NA-P and NA-Q worked as nurse aides on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-05 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview; the facility failed to assure background checks were completed through the State Nurse Aide (NA) registry for 2 (NA-S and NA-T) of 5 employees. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility policy Abuse and Neglect with a revised date of 1/2023 revealed the following: -The facility will screen employees and volunteers prior to working with residents. -Screening will include verification of references, certification, license and background checks. -Before new employees are permitted to work with residents, references provided by the employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background. -The facility will not employ or otherwise engage an individual who has a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. B. Review of 5 employee files on 8/31/23 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit investigations to the State agency within 5 working days related to potential misappropriation of money for Resident 9. The sample size was 13. The facility census was 41. Findings are: A. Review of the facility policy Abuse and Neglect with a revised date of 1/2023 revealed the following: -Reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -The investigation is the process used to try to determine what happened and will begin immediately. -The administrator or designee will make an initial report to the State agency immediately or within 24 hours and a follow up investigation will be submitted within 5 days. B. Review of Resident 9's nursing progress notes revealed the following: -on 5/22/23 at 11:32 AM the resident reported [gender] was missing $10 and an investigation was started; -on 5/25/23 at 5:10 PM the social worker verified the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number NAC 12-006.17 Based on record review and interview, the facility failed to prevent the potential spread of COVID-19 related to testing symptomatic residents for residents 22 and 30. The sample size was 13 and the facility census was 41. Findings are: A. Review of the facility policy Covid Testing Policy with an origination date of 9/23 revealed the Infection Preventionist (IP) and staff should be aware of any unexplained signs and symptoms of respiratory illness. Nursing staff were to test residents for respiratory illness if the following are present and new: -fever or chills, -cough, -shortness of breath or difficulty breathing, -fatigue, -muscle or body aches, -headache, -new loss of taste or smell, -sore throat, -congestion or running nose, -nausea or vomiting, and -diarrhea. B. Review of Resident 22's Minimum Data Set (MDS- a federally mandated comprehensive assessment used in the development of resident care plans) dated 8/21/23 revealed the following: -had diagnoses of Alzheimer's Disease and dementia, -the resident received extensive assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AVERA HEALTH — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.7 | -0.7 vs chain |
| Health inspection | 4 of 5 | 3.5 | +0.5 vs chain |
| Staffing | 1 of 5 | 4.3 | -3.3 vs chain |
| Quality measures | 4 of 5 | 3.1 | +0.9 vs chain |
The other 12 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AVERA HEALTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 02/01/2011 |
| LAFLAN, DOUGLAS | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2011 |
| BECKER, CAROLYN | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| EKEREN, DOUGLAS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2014 |
| GREENEWAY, KATHY | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| HILTUNEN, SCOTT | Individual | CORPORATE DIRECTOR | — | since 07/01/2021 |
| HUNHOFF, BERNIE | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| HURLEY, JOHN | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| KOLECKA, DEBRA | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| LEON, AMY | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| LORANG, THOMAS | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| MIKKELSEN, BETH | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| SCHINDLER, STEVE | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| SCHMEICHEL, STEVE | Individual | CORPORATE DIRECTOR | — | since 07/01/2021 |
| SEIFERT, ROXANNE | Individual | CORPORATE DIRECTOR | — | since 07/01/2021 |
| STEWARD, BRIAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| STROM, RICHARD | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| SUTTON, BOBBY | Individual | CORPORATE DIRECTOR | — | since 06/18/2018 |
| WELBIG, LUCILLE | Individual | CORPORATE DIRECTOR | — | since 02/01/2011 |
CMS files one row per role, so the 21 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285284. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.