Avera Creighton Hospital
A critical access hospital in Creighton, Nebraska 68729
P O Box 186, 1503 Main St, Creighton, Nebraska 68729. (402) 358-5700.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 3 deficiencies cited in the last three years
- 17 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on May 9, 2024: a standard inspection.
3 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 1 month of the last 36. Last cited May 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
May 9, 2024: standard inspection1 deficiency
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Infection Prevent & Control Policies
The inspectors’ words, 394 words
“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 47464 Based on review of CDC guidelines, observation and staff interviews, the CAH (Critical Access Hospital) failed to prevent and control the transmission of potential infections related to Legionella as evidenced by lack of a system to assess and promote water safety to prevent the growth of Coliform spore bacteria that promotes Legionella growth which can cause respiratory infection known as Legionnaire’s Disease. This failed practice had the potential to affect all CAH patients. The facility had 76 inpatient admissions and 52 swing bed admissions for fiscal year 2023. Findings are: A. Review of CDC (Centers for Disease Control and Prevention: Legionella) (Last Reviewed March 25, 2021) stated the “Seven key elements of a Legionella water management program are to: -Establish a water management program team; -Describe the building water systems using text and flow diagrams; -Burden of Waterborne Disease; -Identify areas where Legionella could grow and spread; -Decide where control measures should be applied and how to monitor them; -Establish ways to intervene when control limits are not met; -Make sure the program is running as designed (verification) and is effective (validation); and -Document and communicate all the activities. B. Tour of the hospital with the Facility Service Manager (5/7/2024 from 11:12 AM - 11:32 AM) revealed a lack of any weekly flushing of fixtures, sinks and showers. C. Interview with the Facility Service Manager (5/9/2024 at 9:34 AM) confirmed that the facility did not have a weekly flushing program , lacked a facility water schematic, lacked applied and identified control measures, and interventions when the control measures are not met. The Facility Service Manager stated “the only monitoring completed was water temperatures and oxidant residual (chlorine).” D. Interview with the CEO (Chief Executive Officer) (5/9/2024 at 9:14 AM) confirmed that the facility did not have a weekly flushing program , lacked a facility water schematic, lacked applied and identified control measures, and interventions when the control measures are not met. The CEO stated “they will follow up and get a Legionella plan in place and will include infection control/safety committee in developing the plan.””
May 8, 2024: standard inspection2 deficiencies
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 121 words
“42 CFR 482.41 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. The Avera Creighton Hospital is a one story building of Type III (211) construction. The building is fully sprinkled with smoke detection in the corridors and spaces open to the corridors. Avera Creighton Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”
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Portable Space Heaters
The inspectors’ words, 207 words
“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 39858 Based on observation and interview, the facility allowed the use of portable electric space heaters in an office and a nurse’s station, with no documentation on maximum temperature of the heating element. This deficient practice increased the potential of a fire. The facility has the capacity for 17 beds with a census of 3 on the day of survey. Findings are: Observations on 5-8-24 between 10:05 am and 10:40 am revealed portable electric heating devices in the Cardiac Rehab office and in the Nurse’s Station. During interviews on 5-8-24 between 10:05 am and 10:40 am, Maintenance Staff A confirmed the portable electric heaters. NFPA Standard: 2012 NFPA 101, 19.7.8 Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met: (1) Such devices are used only in nonsleeping staff and employee areas. (2) The heating elements of such devices do not exceed 212°F (100°C)”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| May 9, 2024 | Standard inspection | 1 deficiency cited |
| May 8, 2024 | Standard inspection | 2 deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: readmission, 0 better and 0 worse of 2.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate.
- Emergency department patients spent a median of 107 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Jul 1, 2000.
- Ownership: voluntary non-profit - private.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 85% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Avera Health owns 100% directly since Jul 1, 2011.
- Avera Health runs it.
- 16 owners or officers are people: Barbara Rezac (corporate director, 0%); Richard D Strom (corporate director); Steve Schmeichel (corporate director); Debra Ann Kolecka (corporate director); Lucille F Welbig (corporate director); Steve Schindler (corporate director); Amy Leon (corporate director); Amanda Marie Schutz (corporate officer); Bernie Hunhoff (corporate director); Brian Steward (corporate director); Victoria M Hanson (corporate officer); Victoria M Hanson (managing employee (on the payroll)); John J Hurley (corporate director); Arthur Moeller (corporate director); Amy Miner (corporate director, 0%); Jonathon P Demuth (corporate director, 0%).
- CMS’s Provider of Services file records 4 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Avera Health | Owns 5% or more directly | 100% | Jul 1, 2011 |
| Avera Health | Runs it (operational or managerial control) | Feb 1, 2011 |
How does it compare nearby?
- No other hospital CMS lists is in Knox County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.