Cycle 1
Health 2024-09-12 · Fire 2024-09-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lincoln, NE
St. Jane de Chantal
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
2200 South 52nd Street, Lincoln, NE
(402) 413-3607
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.75
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.49
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
4.14
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
7.38
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
3.24
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
6.84
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
1.65
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.97
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,449
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.60
Composite VBP score used to determine payment impact.
Payment multiplier
1.0117
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.42
Baseline 20.80% · Performance 19.84% · Measure score 3.42 · Achievement 3.42 · Improvement 2.04
Healthcare-associated infections
4.42
Baseline 6.20% · Performance 6.51% · Measure score 4.42 · Achievement 4.42 · Improvement 0
Total nurse turnover
7.95
Baseline 38.97% · Performance 31.18% · Measure score 7.95 · Achievement 7.95 · Improvement 5.02
Adjusted total nurse staffing
6.84
Baseline 5.21 hours · Performance 5.02 hours · Measure score 6.84 · Achievement 6.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 6.79% · Lower 95% interval 6.9% |
| Discharge to community | 62.85% |
50.57%
12.3 pts better
|
Better than the National Rate · Eligible stays 151 · Observed rate 68.21% · Lower 95% interval 55.63% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 114 · Denominator 114 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 114 |
| Discharge self-care score | 60.19% |
53.69%
6.5 pts better
|
Numerator 62 · Denominator 103 |
| Discharge mobility score | 57.28% |
50.94%
6.3 pts better
|
Numerator 59 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 3.51% |
2.29%
1.2 pts worse
|
Numerator 4 · Denominator 114 · Adjusted rate 4.58% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 4.46% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 1.57% |
8.2%
6.6 pts worse
|
Numerator 6 · Denominator 382 |
| Staff flu vaccination coverage | 82.75% |
42%
40.8 pts better
|
Numerator 283 · Denominator 342 |
| Discharge function score | 55.34% |
56.45%
1.1 pts worse
|
Numerator 57 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 71 · Denominator 71 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 35.94% |
25.2%
10.7 pts better
|
Numerator 23 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
92.8%
4.6 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.6% · Q4 94.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
4.5%
2.3 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.5% · Q3 2.9% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.4%
1 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.5% · Q3 0.0% · Q4 6.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.3%
2.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.2% · Q3 1.6% · Q4 1.6% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.3% |
19.5%
19.8 pts worse
|
19.6%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 42.4% · Q3 40.0% · Q4 37.5% · 4Q avg 39.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
21.6%
About the same
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 21.6% · Q3 22.6% · Q4 24.1% · 4Q avg 21.6% · 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 | 27.2% |
20.4%
6.8 pts worse
|
16.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
19.9%
7.9 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 11.1% · Q3 8.3% · Q4 8.3% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.5% |
1.6%
6.9 pts worse
|
1.0%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 9.9% · Q3 9.8% · Q4 6.9% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
2.9%
1.2 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.5% · Q3 6.0% · Q4 1.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
26.6%
0.9 pts better
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 25.8% · Q3 34.0% · Q4 24.0% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.3%
3.5 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.4% · Q3 9.0% · Q4 9.0% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 34.0% |
80.5%
46.5 pts worse
|
81.7%
47.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.9% · Q2 35.9% · Q3 22.3% · Q4 18.3% · 4Q avg 34.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
11.6%
6 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.3% · 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 2.7% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
75.9%
16.6 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.1% |
20.9%
6.8 pts better
|
23.9%
9.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 11.5% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
0 health deficiencies
No concentrated health issue counts in this cycle.
17 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Cycle 3
Health 2022-09-07 · Fire 2022-09-07
2 health deficiencies
Top issue: Environmental (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-17
F · Potential for more than minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-09-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-09-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-17
E · Potential for more than minimal harm
2024-09-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-17
F · Potential for more than minimal harm
2023-10-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-10-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-09-07
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-10-22
F · Potential for more than minimal harm
2022-09-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-03
E · Potential for more than minimal harm
2022-09-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-17
F · Potential for more than minimal harm
2022-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-22
E · Potential for more than minimal harm
2022-09-07
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2022-10-22
Penalties and ownership
What sits behind the stars
Ownership
Cassels, Scott
Corporate Director · Individual
Coffey, John
Corporate Director · Individual
Doane, Heidi
Corporate Director · Individual
Dongilli, Paul
Operational/Managerial Control · Individual
Dongilli, Paul
Corporate Director · Individual
Dongilli, Paul
Corporate Officer · Individual
Dongilli, Paul
W-2 Managing Employee · Individual
Douglas, William
Corporate Director · Individual
Douglas, William
Corporate Officer · Individual
Essay, Phillip
Corporate Director · Individual
Gannon, David
Corporate Director · Individual
Gannon, David
Corporate Officer · Individual
Hayes, Adam
Corporate Director · Individual
Hedderman, Michael
Operational/Managerial Control · Individual
Hedderman, Michael
W-2 Managing Employee · Individual
Lempka, Katherine
Corporate Director · Individual
Lighthall, Maria
Corporate Director · Individual
Mckiernan, Alexander
Corporate Director · Individual
Nietfeldt, Bradley
Corporate Director · Individual
Perkins, Gary
Corporate Director · Individual
Pugliese, Lauren
Corporate Director · Individual
Pugliese, Lauren
Corporate Officer · Individual
Spethman, Patrick
Corporate Director · Individual
Sullivan, John
Corporate Director · Individual
Sullivan, John
Corporate Officer · Individual
Vasek, Gregory
Corporate Director · Individual
Vokoun, Daniel
Corporate Director · Individual
Walker, Sarah
Corporate Director · Individual
Wilwerding, Nicholas
Corporate Director · Individual
Zach, Terence
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Ambassador Health of Lincoln
Lincoln, NE
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Holmes Lake Rehabilitation & Care Center
Lincoln, NE
1-star overall rating with 1-star inspections with $3,174 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Tabitha Nursing Home
Lincoln, NE
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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