Grand Island, NE

CHI Health St. Francis

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

2116 West Faidley Avenue, Grand Island, NE

(308) 398-5880

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

36

Certified beds

Average residents

15

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Commonspirit Health

Operator or chain grouping

Approved since

1987-08-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

3.25

Registered nurse staffing

LPN hours / resident day

0.67

Licensed practical nurse staffing

Aide hours / resident day

4.22

Nurse aide staffing

Weekend hours

7.56

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

46%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.8% 7.2 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	4.5% 4.5 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.8%	5.3% 0.5 pts better	5.4% 0.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.7%	19.5% 3.2 pts worse	19.6% 3.1 pts worse	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents with a catheter inserted and left in their bladder	12.9%	1.6% 11.3 pts worse	1.0% 11.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.8%	2.9% 1.9 pts worse	1.7% 3.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	0.0%	4.3% 4.3 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	80.5% 18.3 pts better	81.7% 17.1 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	8.7%	11.6% 2.9 pts better	12.0% 3.3 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	2.4% 1.2 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.6%	75.9% 18.7 pts better	79.7% 14.9 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.6%	20.9% 7.7 pts worse	23.9% 4.7 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-20 · Fire 2025-03-20

2 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-02-01 · Fire 2024-02-01

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-03-13 · Fire 2023-03-13

2 health deficiencies

Top issue: Environmental (1 deficiency)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-20

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-05-15

F · Potential for more than minimal harm 2025-03-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-15

F · Potential for more than minimal harm 2025-03-20

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-15

E · Potential for more than minimal harm 2024-02-01

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-02-22

E · Potential for more than minimal harm 2024-02-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-02-22

F · Potential for more than minimal harm 2023-03-13

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2023-04-20

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-03-20

F729 · Nursing and Physician Services Deficiencies

Health

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Corrected 2025-05-20

D · Potential for more than minimal harm 2025-03-20

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-05-20

F · Potential for more than minimal harm 2024-02-01

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 2024-03-21

D · Potential for more than minimal harm 2024-02-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-03-21

D · Potential for more than minimal harm 2024-02-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-21

F · Potential for more than minimal harm 2023-03-13

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-03-13

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-04-20

Penalties and ownership

What sits behind the stars

Ownership

Chi Nebraska

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2013-08-01

Commonspirit Health

5% Or Greater Indirect Ownership Interest · Organization

100% 19 facilities 2013-08-01

Bacon, Kelly