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
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
0.98
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.57
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
1.18
CMS adjusted RN staffing hours
Adjusted total hours
5.52
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
33%
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
6,716
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.23% · Performance 24.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.29
Baseline 6.32% · Performance 6.85% · Measure score 3.29 · Achievement 3.29 · Improvement 0
Total nurse turnover
2.98
Performance 51.52% · Measure score 2.98 · Achievement 2.98 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.50
Baseline 4.53 hours · Performance 4.93 hours · Measure score 6.50 · Achievement 6.50 · Improvement 2.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.12% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 9.72% · Lower 95% interval 6.86% |
| Discharge to community | 18.21% |
50.57%
32.4 pts worse
|
Worse than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 11.77% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 72.97% |
95.27%
22.3 pts worse
|
Numerator 27 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 15 · Denominator 30 |
| Discharge mobility score | 56.67% |
50.94%
5.7 pts better
|
Numerator 17 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 4.48% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 97.66% |
42%
55.7 pts better
|
Numerator 125 · Denominator 128 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
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 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| 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 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 5.2% |
4.5%
0.7 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.1% · Q3 6.4% · Q4 6.5% · 4Q avg 5.2% · Used in QM five-star |
| 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 · Q1 7.8% · Q2 7.0% · Q3 4.7% · Q4 8.9% · 4Q avg 7.1% |
| 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 · Q1 2.2% · Q2 0.0% · Q3 2.4% · Q4 2.3% · 4Q avg 1.7% |
| 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 · Q1 10.9% · Q2 13.0% · Q3 18.2% · Q4 17.8% · 4Q avg 14.9% |
| 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 · Q1 9.8% · Q2 5.6% · Q3 10.3% · Q4 15.9% · 4Q avg 10.6% · 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 | 9.7% |
20.4%
10.7 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 13.4% · Q3 4.6% · Q4 6.6% · 4Q avg 9.7% · Used in QM five-star |
| 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 · Q1 18.2% · Q2 18.2% · Q3 7.0% · Q4 9.3% · 4Q avg 13.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 4.4% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 23.9% · Q2 18.8% · Q3 18.7% · Q4 8.3% · 4Q avg 17.6% |
| 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 · Q1 7.3% · Q2 3.7% · Q3 10.4% · Q4 4.3% · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q3 100.0% · Q4 100.0% · 4Q avg 97.4% |
| 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 · Adjusted 7.6% · Observed 6.7% · Expected 9.8% · Used in QM five-star |
| 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 · 4Q avg 12.5% · Used in QM five-star |
| 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 · Adjusted 20.3% · Observed 13.3% · Expected 15.7% · Used in QM five-star |
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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