Cycle 1
Health 2024-12-17 · Fire 2024-12-17
8 health deficiencies
Top issue: Infection Control (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Norfolk, NE
St. Joseph's Rehabilitation and Care Center
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
401 North 18thStreet, Norfolk, NE
(402) 644-7375
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1995-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,000
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.33
Baseline 18.30% · Performance 19.89% · Measure score 3.33 · Achievement 3.33 · Improvement 0
Healthcare-associated infections
2.96
Baseline 5.14% · Performance 6.95% · Measure score 2.96 · Achievement 2.96 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4
Baseline 4.31 hours · Performance 4.22 hours · Measure score 4 · Achievement 4 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 6.85% · Lower 95% interval 6.33% |
| Discharge to community | 43.72% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 38.6% · Lower 95% interval 34% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 54 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 51.06% |
53.69%
2.6 pts worse
|
Numerator 24 · Denominator 47 |
| Discharge mobility score | 29.79% |
50.94%
21.1 pts worse
|
Numerator 14 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 2.1% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 5 · Denominator 77 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 62 · Denominator 124 |
| Discharge function score | 46.81% |
56.45%
9.6 pts worse
|
Numerator 22 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 32.35% |
25.2%
7.2 pts better
|
Numerator 11 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.7 · 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 | 91.9% |
92.8%
0.9 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 94.3% · Q3 94.6% · Q4 81.1% · 4Q avg 91.9% |
| 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 | 4.0% |
4.5%
0.5 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.9% · Q3 5.4% · Q4 2.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.3% |
4.4%
9.9 pts worse
|
11.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.1% · Q3 18.2% · Q4 11.1% · 4Q avg 14.3% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.3%
3.5 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 10.3% · Q3 11.1% · Q4 3.1% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
19.5%
1.4 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 13.3% · Q3 24.1% · Q4 28.1% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
21.6%
0.5 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.7% · Q3 26.9% · Q4 23.1% · 4Q avg 22.1% · 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 | 36.7% |
20.4%
16.3 pts worse
|
16.3%
20.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
19.9%
4.7 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 21.4% · Q3 14.8% · Q4 22.6% · 4Q avg 24.6% · 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 | 1.4% |
2.9%
1.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.4% |
26.6%
12.8 pts worse
|
19.8%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 47.6% · Q3 53.5% · Q4 33.6% · 4Q avg 39.4% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.3%
2.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.7% · Q3 5.7% · Q4 5.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
80.5%
3.7 pts better
|
81.7%
2.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 93.8% · Q3 91.5% · Q4 63.5% · 4Q avg 84.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.9% |
11.6%
10.3 pts worse
|
12.0%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 21.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short 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 who were assessed and appropriately given the seasonal influenza vaccine | 92.4% |
75.9%
16.5 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
20.9%
0.8 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 21.7% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-28 · Fire 2023-11-28
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-17
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 2024-12-31
F · Potential for more than minimal harm
2023-11-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-28
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 2023-12-11
D · Potential for more than minimal harm
2023-11-28
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 2023-12-11
F · Potential for more than minimal harm
2022-10-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-27
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 2022-11-10
E · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-27
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 2022-11-10
D · Potential for more than minimal harm
2022-10-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-11-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-17
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 2025-01-27
E · Potential for more than minimal harm
2024-12-17
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 2025-01-27
E · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-17
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 2025-01-27
D · Potential for more than minimal harm
2024-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-27
F · Potential for more than minimal harm
2023-11-28
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 2024-01-05
E · Potential for more than minimal harm
2023-11-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
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 2024-01-05
D · Potential for more than minimal harm
2023-11-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-05
F · Potential for more than minimal harm
2022-10-27
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 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-11
D · Potential for more than minimal harm
2022-10-27
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 2022-12-11
Penalties and ownership
What sits behind the stars
Ownership
Burnam, Soon
Corporate Officer · Individual
Miller, Blake
Operational/Managerial Control · Individual
Recob, Samuel
Operational/Managerial Control · Individual
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#2
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#3
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