Holdrege, NE

Christian Homes Health Care Center

1-star overall rating with 2-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1923 West 4th Avenue, Holdrege, NE

(308) 995-4493

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

86

Certified beds

Average residents

70

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2002-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.64

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.70

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

2.48

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

3.82

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

3.42

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.69

CMS adjusted RN staffing hours

Adjusted total hours

4.11

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,732

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

Performance score

48.07

Composite VBP score used to determine payment impact.

Payment multiplier

1.0017

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.21

Performance 18.09% · Measure score 7.21 · Achievement 7.21 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

6.37

Baseline 5.79% · Performance 5.93% · Measure score 6.37 · Achievement 6.37 · Improvement 0

Total nurse turnover

0.70

Baseline 48.15% · Performance 60.81% · Measure score 0.70 · Achievement 0.70 · Improvement 0

Adjusted total nurse staffing

4.94

Baseline 3.84 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 2.83

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.87%	10.72% 1.9 pts better	No Different than the National Rate · Eligible stays 103 · Observed rate 3.88% · Lower 95% interval 6.57%
Discharge to community	41.95%	50.57% 8.6 pts worse	No Different than the National Rate · Eligible stays 76 · Observed rate 38.16% · Lower 95% interval 33.99%
Medicare spending per beneficiary	0.93	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 81 · Denominator 81
Falls with major injury	4.94%	0.77% 4.2 pts worse	Numerator 4 · Denominator 81
Discharge self-care score	31.25%	53.69% 22.4 pts worse	Numerator 20 · Denominator 64
Discharge mobility score	32.81%	50.94% 18.1 pts worse	Numerator 21 · Denominator 64
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 81 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	5.93%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 67 · Observed rate 1.49% · Lower 95% interval 3.19%
Staff COVID-19 vaccination coverage	9.43%	8.2% 1.2 pts better	Numerator 5 · Denominator 53
Staff flu vaccination coverage	85.15%	42% 43.2 pts better	Numerator 86 · Denominator 101
Discharge function score	39.06%	56.45% 17.4 pts worse	Numerator 25 · Denominator 64
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	19.15%	25.2% 6.1 pts worse	Numerator 9 · Denominator 47

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.2 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.5	2.0 1.5 pts worse	1.8 1.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.0 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	92.8% 6 pts better	93.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.3% · Q4 100.0% · 4Q avg 98.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.4%	96.1% 2.3 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4%
Percentage of long-stay residents experiencing one or more falls with major injury	7.5%	4.5% 3 pts worse	3.3% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.7% · Q3 7.8% · Q4 9.4% · 4Q avg 7.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.4% 4.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	7.8%	5.3% 2.5 pts worse	5.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.8% · Q3 7.7% · Q4 3.5% · 4Q avg 7.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.6%	19.5% 1.1 pts worse	19.6% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.7% · Q3 20.3% · Q4 20.0% · 4Q avg 20.6%
Percentage of long-stay residents who received an antipsychotic medication	26.1%	21.6% 4.5 pts worse	16.7% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 25.0% · Q3 23.9% · Q4 29.2% · 4Q avg 26.1% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	24.1%	20.4% 3.7 pts worse	16.3% 7.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 12.0% · Q3 29.6% · Q4 24.2% · 4Q avg 24.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.2%	19.9% 4.3 pts worse	14.9% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 14.8% · Q3 30.9% · Q4 21.4% · 4Q avg 24.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.2%	1.6% 0.6 pts worse	1.0% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.5% · Q4 1.8% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	2.9% 2 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.2%	26.6% 2.6 pts worse	19.8% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 29.9% · Q3 38.6% · Q4 18.5% · 4Q avg 29.2%
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.6%	80.5% 17.1 pts better	81.7% 15.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.9% · Q3 94.7% · Q4 100.0% · 4Q avg 97.6%
Percentage of short-stay residents who had an outpatient emergency department visit	18.5%	11.6% 6.9 pts worse	12.0% 6.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.8% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	2.4% 1.3 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.7%	75.9% 13.8 pts better	79.7% 10 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.0%	20.9% 2.1 pts worse	23.9% 0.9 pts better	Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 21.9% · Expected 22.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-05 · Fire 2024-12-05

12 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 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: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)

Cycle 3 Health 2023-03-02 · Fire 2023-03-02

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

6 fire-safety deficiencies

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

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-05

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-01-19

E · Potential for more than minimal harm 2024-12-05

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-01-19

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

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-03-17

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

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-03-17

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

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2024-03-17

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

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-03-17

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

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-03-17

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

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-03-17

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 2024-03-17

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

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-03-17

F · Potential for more than minimal harm 2023-03-02

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-04-16

F · Potential for more than minimal harm 2023-03-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-04-16

F · Potential for more than minimal harm 2023-03-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-04-16

F · Potential for more than minimal harm 2023-03-02

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2023-04-16

D · Potential for more than minimal harm 2023-03-02

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-16

D · Potential for more than minimal harm 2023-03-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-04-16

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-04

F · Potential for more than minimal harm 2025-04-08

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2025-04-30

F · Potential for more than minimal harm 2025-04-08

F844 · Administration Deficiencies

Health

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Corrected 2025-04-30

D · Potential for more than minimal harm 2025-01-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-01-19

E · Potential for more than minimal harm 2024-12-05

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-01-19