Cycle 1
Health 2025-03-13 · Fire 2025-03-13
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
West Point, NE
St Joseph's Hillside Villa
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
540 E Washington Street, West Point, NE
(402) 372-1118
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2019-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing
LPN hours / resident day
0.42
Licensed practical nurse staffing
Aide hours / resident day
3.17
Nurse aide staffing
Weekend hours
4.02
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| 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 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
4.5%
0.7 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
4.4%
2.7 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.3%
3.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
19.5%
4.6 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
21.6%
11 pts better
|
16.7%
6.1 pts better
|
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 whose ability to walk independently worsened | 9.7% |
20.4%
10.7 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
19.9%
6.7 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.9%
1.3 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
26.6%
9 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.3%
2.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
80.5%
16.9 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.6%
4 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 12.5% |
2.4%
10.1 pts worse
|
1.6%
10.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
20.9%
0.6 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-13
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-03-13
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-07
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-03-29
F · Potential for more than minimal harm
2023-02-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-02-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-07
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 2023-03-07
F · Potential for more than minimal harm
2023-02-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-07
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-07
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-07
F · Potential for more than minimal harm
2023-02-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-15
F · Potential for more than minimal harm
2023-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-02-07
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-03-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-27
D · Potential for more than minimal harm
2024-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-03-07
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 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-24
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 2023-05-12
D · Potential for more than minimal harm
2023-03-15
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 2023-04-07
D · Potential for more than minimal harm
2023-03-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-02-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-01
E · Potential for more than minimal harm
2023-02-07
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 2023-03-01
E · Potential for more than minimal harm
2023-02-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-07
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-01
Penalties and ownership
What sits behind the stars
Ownership
Falk, Theresa
Corporate Director · Individual
Falk, Theresa
Corporate Officer · Individual
Franciscan Sisters Of Christian Charity Sponsored Ministries, Inc.
Operational/Managerial Control · Organization
Graybeal, Michael
Corporate Director · Individual
Graybeal, Michael
Corporate Officer · Individual
Hass, Brian
Operational/Managerial Control · Individual
Hass, Brian
Contracted Managing Employee · Individual
Holy Family Convent Of Franciscan Sisters Of Christian Charity Inc
Operational/Managerial Control · Organization
Loch, Timothy
Operational/Managerial Control · Individual
Loch, Timothy
Corporate Director · Individual
Loch, Timothy
Corporate Officer · Individual
Loch, Timothy
W-2 Managing Employee · Individual
Reimers, Brian
Corporate Director · Individual
Reimers, Brian
Corporate Officer · Individual
Rose, Joy
Corporate Director · Individual
Steffensmeier, David
Corporate Director · Individual
Troyer, Amy
Operational/Managerial Control · Individual
Troyer, Amy
Corporate Officer · Individual
Troyer, Amy
W-2 Managing Employee · Individual
White, Diane
Corporate Director · Individual
White, Diane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Colonial Haven
Beemer, NE
4-star overall rating with 5-star inspections with $4,580 in total fines with 3 fire-safety deficiencies in the latest cycle
#2
Oakland Heights
Oakland, NE
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Wisner Care Center
Wisner, NE
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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