Cycle 1
Health 2025-12-04 · Fire 2025-12-04
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grand Island, NE
Tiffany Square
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3119 West Faidley Avenue, Grand Island, NE
(308) 384-2333
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vetter Senior Living
Operator or chain grouping
Approved since
1989-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 4 health / 4 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
0.53
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.59
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,866
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.86
Baseline 20.29% · Performance 18.72% · Measure score 5.86 · Achievement 5.86 · Improvement 4.33
Healthcare-associated infections
0
Baseline 6.68% · Performance 8.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.90
Baseline 27.85% · Performance 35.48% · Measure score 6.90 · Achievement 6.90 · Improvement 0
Adjusted total nurse staffing
2.57
Baseline 4.32 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 7.75% · Lower 95% interval 6.37% |
| Discharge to community | 56.07% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 50% · Lower 95% interval 48.33% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 78 · Denominator 78 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 2 · Denominator 78 |
| Discharge self-care score | 12.7% |
53.69%
41 pts worse
|
Numerator 8 · Denominator 63 |
| Discharge mobility score | 14.29% |
50.94%
36.6 pts worse
|
Numerator 9 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 78 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | 8.71% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 10.67% · Lower 95% interval 5.31% |
| Staff COVID-19 vaccination coverage | 0.68% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 148 |
| Staff flu vaccination coverage | 66.44% |
42%
24.4 pts better
|
Numerator 99 · Denominator 149 |
| Discharge function score | 15.87% |
56.45%
40.6 pts worse
|
Numerator 10 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.22% |
96.28%
0.9 pts better
|
Numerator 35 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 31.58% |
25.2%
6.4 pts better
|
Numerator 12 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.9% |
92.8%
13.9 pts worse
|
93.4%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.1% · Q2 73.1% · Q3 78.6% · Q4 86.8% · 4Q avg 78.9% |
| 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 | 2.2% |
4.5%
2.3 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.5% · Q3 1.4% · Q4 2.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.4%
3.6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.3%
2.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 1.8% · Q3 1.7% · Q4 1.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
19.5%
5.5 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 12.1% · Q3 11.3% · Q4 17.5% · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
21.6%
10.5 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 10.4% · Q3 7.8% · Q4 10.2% · 4Q avg 11.1% · 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 | 32.0% |
20.4%
11.6 pts worse
|
16.3%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 45.4% · Q4 21.9% · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.8% |
19.9%
5.9 pts worse
|
14.9%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 25.0% · Q3 19.7% · Q4 31.7% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
1.6%
1.4 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 4.5% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.9%
0.9 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.7% · Q3 4.4% · Q4 6.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
26.6%
6.3 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 41.1% · Q3 26.5% · Q4 21.1% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.3%
0.9 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.7% · Q3 6.7% · Q4 3.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
80.5%
2 pts better
|
81.7%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 76.9% · Q3 74.5% · Q4 91.7% · 4Q avg 82.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.6%
3.8 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 12.5% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.4%
0.7 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.4% |
75.9%
2.5 pts better
|
79.7%
1.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
20.9%
About the same
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 17.2% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-16 · Fire 2024-10-16
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-10-05 · Fire 2023-10-05
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-12-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-12-31
F · Potential for more than minimal harm
2024-10-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-16
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-10-05
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-17
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
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
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 2023-11-17
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
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-01-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
E · Potential for more than minimal harm
2024-10-16
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 2024-11-20
E · Potential for more than minimal harm
2024-10-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-16
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 2024-11-20
D · Potential for more than minimal harm
2024-10-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-02-14
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 2024-03-20
F · Potential for more than minimal harm
2023-10-05
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 2023-11-17
D · Potential for more than minimal harm
2023-10-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
C · Minimal harm
2023-10-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-17
Penalties and ownership
What sits behind the stars
Ownership
Vetter Senior Living
5% Or Greater Direct Ownership Interest · Organization
Fruehling, Richard
Operational/Managerial Control · Individual
Fruehling, Richard
Contracted Managing Employee · Individual
Olson, Stephanie
Operational/Managerial Control · Individual
Olson, Stephanie
Contracted Managing Employee · Individual
Stuhr, Brian
Operational/Managerial Control · Individual
Stuhr, Brian
Corporate Officer · Individual
Stuhr, Brian
Contracted Managing Employee · Individual
Vanekeren, Glenn
Operational/Managerial Control · Individual
Vanekeren, Glenn
Corporate Officer · Individual
Vanekeren, Glenn
Contracted Managing Employee · Individual
Vetter Senior Living
Operational/Managerial Control · Organization
Vetter, Eldora
Operational/Managerial Control · Individual
Vetter, Eldora
Corporate Officer · Individual
Vetter, Eldora
Contracted Managing Employee · Individual
Vetter, Jack
Operational/Managerial Control · Individual
Vetter, Jack
Corporate Officer · Individual
Vetter, Jack
Contracted Managing Employee · Individual
Vsl Vetter Health Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Grand Island Village
Grand Island, NE
1-star overall rating with 2-star inspections with $10,033 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
CHI Health St. Francis
Grand Island, NE
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Cedars at Broadwell
Grand Island, NE
1-star overall rating with 1-star inspections with $16,801 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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