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

Chain footprint

19 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 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

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

3.25

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

4.22

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

8.15

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

3.93

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

7.56

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

2.22

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.45

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

2.76

CMS adjusted RN staffing hours

Adjusted total hours

6.90

CMS adjusted total nurse staffing hours

Case-mix index

1.62

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,768

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9917

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.34

Baseline 19.00% · Performance 20.35% · Measure score 2.34 · Achievement 2.34 · Improvement 0

Healthcare-associated infections

4.16

Baseline 6.67% · Performance 6.59% · Measure score 4.16 · Achievement 4.16 · Improvement 0

Total nurse turnover

5.09

Performance 42.86% · Measure score 5.09 · Achievement 5.09 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.37%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 145 · Observed rate 11.72% · Lower 95% interval 8.58%
Discharge to community	68.73%	50.57% 18.2 pts better	Better than the National Rate · Eligible stays 133 · Observed rate 69.92% · Lower 95% interval 60.54%
Medicare spending per beneficiary	0.8	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 24 · Denominator 24
Falls with major injury	4.17%	0.77% 3.4 pts worse	Numerator 1 · Denominator 24
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 24 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.59%	7.12% 0.5 pts better	No Different than the National Rate · Eligible stays 87 · Observed rate 4.6% · Lower 95% interval 3.55%
Staff COVID-19 vaccination coverage	2.38%	8.2% 5.8 pts worse	Numerator 1 · Denominator 42
Staff flu vaccination coverage	72.73%	42% 30.7 pts better	Numerator 32 · Denominator 44
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

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 · 4Q avg 100.0%
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 · 4Q avg 0.0% · Used in QM five-star
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 · 4Q avg 4.8%
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 · 4Q avg 22.7%
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 · 4Q avg 0.0%
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 · 4Q avg 12.9% · Used in QM five-star
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 · 4Q avg 4.8% · Used in QM five-star
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 · 4Q avg 0.0% · Used in QM five-star
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 · Q1 98.9% · Q2 98.9% · Q3 98.8% · Q4 98.6% · 4Q avg 98.8%
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 · Adjusted 8.7% · Observed 7.7% · Expected 9.9% · Used in QM five-star
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 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 2.1% · 4Q avg 1.2% · Used in QM five-star
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 · 4Q avg 94.6%
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 · Adjusted 28.6% · Observed 23.1% · Expected 19.2% · Used in QM five-star

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