Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Creighton Care Centre during CMS and state inspections, most recent first.
A facility failed to complete hand hygiene at required intervals during resident care, including after glove removal, before donning clean gloves, and before exiting resident rooms. Observations showed NAs and an RN providing toileting, catheter, ostomy, wound, and incontinence care for residents with dementia, paraplegia, pressure ulcers, and other care needs while skipping hand hygiene between dirty and clean tasks and while moving between contaminated and clean activities. Staff also touched resident items and equipment while wearing soiled gloves, and the DON confirmed the missed hand hygiene during the survey.
A resident with PTSD, anxiety, depression, and episodes of disorganized thinking had behaviors including delusions, resistance to cares, and verbal outbursts, but the care plan did not identify PTSD triggers or interventions to address them. Notes documented that being in the bathroom could trigger anxiety because of past trauma, and a PMHNP later recorded nightmares, poor sleep, flashbacks, and visual hallucinations; the DON confirmed the care plan did not list PTSD triggers or related interventions.
Failure to follow hot liquid spill precautions for a resident with dementia, tremor, and impaired decision-making. The resident was initially assessed as low risk and was to wear one clothing protector in the dining room, but after a hot water spill occurred when no protector had been placed, the resident's risk increased and two protectors were required. Later dining room observations showed the resident being served hot cereal and soup while wearing only one protector, with the lap protector not in place.
A resident with PTSD, anxiety, depression, and episodes of disorganized thinking had repeated distress, tearfulness, verbal behaviors, nightmares, flashbacks, and anxiety tied to past abuse. Although the care plan addressed general behaviors, the record showed no evidence the facility identified PTSD triggers or resident preferences, and the DON confirmed no triggers or interventions were in place; the SSD also stated the facility had no Trauma Informed Care policy.
The facility failed to follow proper infection control protocols during meal service, as observed with dietary aides not using the required PPE, such as N95 masks and eye protection, and not performing hand hygiene consistently. This non-compliance was confirmed by the DON, who noted that staff had not received recent training on PPE use during a COVID-19 outbreak.
The facility failed to account for narcotic medications according to policy, affecting several residents. Discrepancies were found between recorded counts and actual pills remaining, as staff did not update controlled substance records immediately after administration. The Director of Nursing confirmed the expectation for immediate record updates to ensure accuracy.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to complete hand hygiene at appropriate intervals during resident care, including after glove removal, before putting on clean gloves, and before exiting resident rooms. The deficiency was identified through observation, record review, and interview, and involved multiple residents during toileting, catheter, ostomy, and wound care activities. Facility policies reviewed by surveyors stated that hand hygiene was the primary means of preventing transmission of infection and was to be completed before and after resident contact, after contact with body fluids or contaminated surfaces, and after removing gloves. Resident 28 required extensive assistance with transfers, dressing, toileting, and personal hygiene and had disorganized thinking, non-Alzheimer dementia, and anxiety. During observed care, a NA transferred the resident with a mechanical lift, removed clothing and an incontinent brief, assisted the resident to the toilet, touched the bed and the resident’s face and hair while wearing gloves, then provided perineal care and assisted the resident back to bed without washing hands after glove removal or before leaving the room. Resident 12 had an indwelling catheter, an ostomy, paraplegia, limited range of motion, and required assistance with toileting, dressing, and transfers. During observed catheter and ostomy care, two NAs removed soiled gloves and put on clean gloves without hand hygiene between tasks, and one NA did not wash hands before exiting the room. Resident 1 had a pressure ulcer to the right facial cheek and an open area to the right side of the coccyx. During wound care, an RN removed a band-aide from the cheek, cleansed and redressed the wound, then removed gloves and used hand sanitizer, but did not change gloves or wash hands between removing the soiled dressing and applying the clean dressing. The RN repeated the same pattern for the coccyx wound. Resident 20 required assistance with dressing, mobility, and transfers; during toileting care, a NA removed gloves without hand hygiene, later applied clean gloves without hand hygiene, performed perineal care, continued wearing soiled gloves while pulling clothing up, and then removed gloves without hand hygiene until later exiting the room. Resident 36 had severe cognitive impairment and was dependent for oral hygiene, toileting, dressing, and personal hygiene; during toileting care, a NA entered without hand hygiene, removed gloves without hand hygiene, reapplied clean gloves without hand hygiene, continued care while wearing the same soiled gloves, touched the resident’s clothing, walker, and wheelchair, and then removed gloves and exited without hand hygiene. Resident 3 was observed during incontinence care with two staff members who entered without hand hygiene, applied clean gloves, handled fecal contamination, removed gloves without hand hygiene before re-gloving, and only later completed hand hygiene after the resident was moved back to the wheelchair.
Care Plan Missing PTSD Triggers and Interventions
Penalty
Summary
The facility failed to ensure Resident 2’s PTSD triggers and interventions to address those triggers were identified in the resident care plan. Resident 2 was admitted with diagnoses including anxiety, depression, lung disease, and heart failure, and the MDS noted the resident was cognitively intact but had episodes of disorganized thinking, along with delusions, resistance to cares, and verbal behaviors toward others. The current care plan addressed verbal behaviors, resistance to cares, delirium, impulsivity, and included interventions such as monitoring Duloxetine and Trazadone, allowing time to verbalize concerns, helping solve problems, reorienting as needed, and reapproaching as needed. A nursing progress note documented that the resident was seated in the bathroom, tearful, anxious, and short of breath, and reported a history of PTSD related to being locked in a bathroom or closet by an ex-spouse, stating that being in the bathroom increased anxiety and could cause the resident to "freak out." A psychiatric progress note later documented ongoing PTSD, depression, anxiety, insomnia, nightmare disorder, nightmares most nights, 1-3 hours of sleep per night, some visual hallucinations, and flashbacks, with a new order for Prazosin at bedtime. Review of the current care plan showed no evidence that PTSD was identified with potential triggers or interventions to address those triggers, and the DON confirmed the care plan did not list potential PTSD triggers and no interventions were in place to prevent them.
Failure to Follow Hot Liquid Spill Precautions
Penalty
Summary
The facility failed to implement assessed interventions to prevent a potential injury from a hot liquid spill for a resident with anemia, Alzheimer's disease, depression, severe cognitive impairment, and a tremor. The resident's hot liquid risk screening initially showed a score of 4, indicating low risk, and the resident was identified as consuming hot liquids, having poor decision-making abilities, and requiring assistance with eating. The screening indicated the resident was to wear one clothing protector at all times when in the dining room and when consuming hot liquids. After a hot liquid spill occurred when the resident was given a cup of hot water during Bingo and no protective cover had been placed on the resident, the resident's risk screening was updated to a score of 6. The new interventions required two vinyl clothing protectors in the dining room, one around the neck and one across the lap, and staff were to fill the resident's cup only half full when serving hot liquids. During later observations in the dining room, the resident was served hot cereal and soup while wearing only one clothing protector around the neck, and the second protector across the lap was not in place.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma informed and culturally competent care for a resident with PTSD, anxiety, depression, lung disease, and heart failure. The resident’s MDS showed the resident was cognitively intact but had episodes of disorganized thinking, delusions, resistance with cares, and verbal behaviors toward others. The care plan addressed verbal behaviors, delirium, impulsivity, and comments about being held prisoner, with interventions such as allowing time to verbalize concerns, helping solve problems, reorienting as needed, and reapproaching when the resident calmed down, but the record contained no evidence that the facility attempted to identify PTSD triggers or resident preferences to reduce or prevent re-traumatization. Nursing notes documented episodes of crying out for help, tearfulness, negative self-comments, anxiety, shortness of breath, and statements that the resident had PTSD and that being in the bathroom could increase anxiety because an ex-spouse had locked the resident in a bathroom or closet. The resident also reported nightmares, flashbacks, and visual hallucinations during psychiatric follow-up, and a new order for prazosin was received for PTSD-related nightmares. During interview, the resident stated the facility had not interviewed the resident about PTSD triggers or possible interventions, and the DON confirmed no triggers had been identified and no interventions were in place. The SSD stated the facility did not have a policy related to Trauma Informed Care and was not aware of any triggers or interventions for the resident.
Inadequate PPE Use and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during room tray meal service, which had the potential to affect all residents. Observations revealed that a dietary aide (DA-A) did not follow the required personal protective equipment (PPE) guidelines when entering rooms of residents on Airborne Respirator Precautions and Contact Precautions. DA-A entered a resident's room wearing only a surgical mask instead of the required N95 mask and eye protection. Additionally, DA-A did not perform hand hygiene consistently between resident contacts and failed to change masks appropriately, which is against the facility's policy. Further observations showed that another dietary aide (DA-B) also did not adhere to PPE protocols, as they entered a resident's room without wearing the necessary face shield or eye protection. DA-B also failed to perform hand hygiene before putting on new PPE. Interviews with the Director of Nursing confirmed that staff were expected to follow specific PPE protocols, including wearing an N95 mask, face shield or goggles, gown, and gloves, and performing hand hygiene before and after PPE use. The dietary staff had not received recent training on PPE use during a COVID-19 outbreak, contributing to these deficiencies.
Narcotic Medication Discrepancies
Penalty
Summary
The facility failed to properly account for narcotic medications according to its policy, which had the potential to affect several residents. The policy required all scheduled controlled medications to be kept in double-locked locations on the medication cart, with a controlled substance record documenting the administration details. However, during an observation of a medication pass, discrepancies were noted in the narcotic counts. For instance, a Registered Nurse (RN) administered Oxycodone to a resident and documented it, but the count did not match the pills remaining. The RN then adjusted the record to account for a previous administration that had not been documented. Further observations revealed similar discrepancies with other residents' narcotic medications. A Licensed Practical Nurse (LPN) administered Tramadol to a resident but did not have the controlled substance record available on the cart, intending to update it later. This led to mismatches between the recorded counts and the actual pills remaining in the medication cassettes for multiple residents. The Director of Nursing confirmed that staff were expected to update the controlled substance record immediately after administering narcotic medications to ensure accuracy and prevent errors.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Creighton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plainview Manor | 10 mi | ★★★★★ | 10 | 0 |
| Alpine Village Retirement Center | 10.7 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Bloomfield | 16.4 mi | ★★★★★ | 8 | 0 |
| Accura Healthcare Of Neligh | 23.6 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Pierce | 27.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.