Chi Health St Francis: Data Analysis and Ratings
CMS Five Star Rating(3 out of 5):
2116 WEST FAIDLEY AVENUE GRAND ISLAND, NE 68803
308-398-5880
Data date: May 01, 2023
The Most Important Data about Chi Health St Francis
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Chi Health St Francis. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(3 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Improving
Total Nursing Hours Spent Per Resident Per Day: 7.70
(The national average is 3.74 )
According to our analysis, Chi Health St Francis is ranked #6 out of 13 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Chi Health St Francis.
What is this page all about?
Below is everything shred of information that we can find about Chi Health St Francis, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: May 01, 2023
Address: 2116 WEST FAIDLEY AVENUE
GRAND ISLAND, NE 68803
Phone: 308-398-5880
Ranking: Chi Health St Francis is ranked #2 out of 5 facilities within a 10 mile radius and #6 out of 13 facilities within a 25 mile radius.
Medicare Provider Number: 285081
Participating in Medicare Since: August 20, 1987
No. of Certified Beds: 36
No. of Residents: 17
Occupancy: 47.22 % (as of 05/21/2023 )
Amount fined in recent period: $23,405.14
Complaints filed: 0
Ratings History for Chi Health St Francis
Review of Chi Health St Francis Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 3: |
| Health Inspection Rating | 2: |
| Quality Rating | 3: |
| Staffing Rating | 5: |
Inspection Scores
| Cycle 1 Score (as of March 13, 2023) | 24 |
| Cycle 2 Score (as of November 15, 2021) | 16 |
| Cycle 3 Score (as of January 06, 2020) | 254 |
| Weighted All Cycles Score | 60 |
It has been 1 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Chi Health St Francis including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | March 14, 2023 |
| Fire Safety Standard | November 15, 2021 |
| Fire Safety Standard | January 02, 2020 |
| Health Standard | March 13, 2023 |
| Health Standard | November 15, 2021 |
| Health Standard | January 06, 2020 |
| Infection Control | August 05, 2020 |
| Infection Control | June 19, 2020 |
Owner and Operator Information for Chi Health St Francis
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
SAINT FRANCIS MEDICAL CENTER
Owners:
- CHI NEBRASKA (DIRECT- 100%)
- COMMONSPIRIT HEALTH (INDIRECT)
Managers and Directors:
- KELLY BACON (DIRECTOR)
- WILLIAM BARNEY (DIRECTOR)
- KEVIN FITZGERALD (DIRECTOR)
- KIRTIBALA GUPTA (DIRECTOR)
- EDWARD HANNON (MANAGING EMPLOYEE)
- NADINE HEIMANN (DIRECTOR)
- SUZANNE HRUZA (DIRECTOR)
- EVERT KUIPER (OPERATIONAL/MANAGERIAL CONTROL)
- EVERT KUIPER (DIRECTOR)
- HEATHER MORGAN (DIRECTOR)
- NICK O'TOOL (OPERATIONAL/MANAGERIAL CONTROL)
- JOHN PETERSDORF (DIRECTOR)
- MAURITA SOUKUP (DIRECTOR)
- MARDELL WILSON (DIRECTOR)
- WILLIAM YATES (DIRECTOR)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Chi Health St Francis spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 3.70 | 0.71 / 0.65 |
| Case Mix | 0.53 | 0.33 / 0.39 |
| Adjusted | 2.72 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.31 | 0.68 / 0.88 |
| Case Mix | 0.85 | NA / NA |
| Adjusted | 0.27 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 3.69 | 2.52 / 2.21 |
| Case Mix | 2.18 | NA / NA |
| Adjusted | 3.45 | NA / NA |
| Total Licensed Staff | ||
| Hours | 4.01 | 1.39 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.36 | 0.05 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 7.70 | 3.91 / 3.74 |
| Case Mix | 3.55 | 3.01 / 3.16 |
| Adjusted | 6.85 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison | |
|---|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 29.2% |
20.2% Worse |
|
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 12.7% |
10.8% Worse |
|
| Number of hospitalizations per 1000 long-stay resident days (qm551) | Not Available | ||
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | Not Available | ||
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 3.8% |
14.7% Better |
|
| Percentage of long-stay residents who lose too much weight (qm404) | 3.4% |
5.8% Better |
|
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | Not Available | ||
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 0.0% |
2.4% Better |
|
| Percentage of long-stay residents with a urinary tract infection (qm407) | 3.4% |
3.8% Better |
|
| Percentage of long-stay residents who have depressive symptoms (qm408) | 0.0% |
4.0% Better |
|
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.2% Better |
|
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 6.7% |
4.7% Worse |
|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 100.0% |
91.3% Better |
|
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 23.3% |
18.7% Worse |
|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 100.0% |
78.2% Better |
|
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 3.0% |
1.9% Worse |
|
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | Not Available | ||
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 36.7% |
19.6% Worse |
|
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 4.3% |
6.3% Better |
|
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 100.0% |
95.8% Better |
|
| Percentage of short-stay residents who made improvements in function (qm471) | 93.1% |
79.3% Better |
|
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 96.4% |
72.5% Better |
|
Chi Health St Francis Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $23,405.14, Complaints filed: 0
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. (Fire Safety) | 01-02-2020 / 02-13-2020 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Health) | 01-06-2020 / 02-13-2020 |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Health) | 01-06-2020 / 02-13-2020 |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Health) | 01-06-2020 / 02-13-2020 |
| Assure that each resident?s assessment is updated at least once every 3 months. (Health) | 01-06-2020 / 02-13-2020 |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. (Health) | 01-06-2020 / 02-13-2020 |
| Ensure each resident receives an accurate assessment. (Health) | 01-06-2020 / 02-13-2020 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Health) | 01-06-2020 / 02-13-2020 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 01-06-2020 / 02-13-2020 |
| Ensure services provided by the nursing facility meet professional standards of quality. (Health) | 01-06-2020 / 02-13-2020 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Health) | 01-06-2020 / 02-13-2020 |
| 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. (Health) | 01-06-2020 / 02-13-2020 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 01-06-2020 / 02-13-2020 |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Health) | 01-06-2020 / 02-13-2020 |
| Provide and implement an infection prevention and control program. (Health) | 01-06-2020 / 02-13-2020 |
| Provide and implement an infection prevention and control program. (Health) | 06-19-2020 / 07-22-2020 |
| 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. (Health) | 11-15-2021 / 12-07-2021 |
| Provide and implement an infection prevention and control program. (Health) | 11-15-2021 / 12-07-2021 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Health) | 03-13-2023 / 04-20-2023 |
| Have enough outside ventilation via a window or mechanical ventilation, or both. (Health) | 03-13-2023 / 03-20-2023 |
| Ensure that testing and maintenance of electrical equipment is performed. (Fire Safety) | 03-14-2023 / 04-20-2023 |
Hospitals Near Chi Health St Francis
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Chi Health St Francis.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
CHI HEALTH ST. FRANCIS 2620 WEST FAIDLEY AVE GRAND ISLAND, NE 68803 |
3 |
|
MARY LANNING HEALTHCARE 715 N ST JOSEPH AVE HASTINGS, NE 68901 |
4 |
|
GRAND ISLAND REGIONAL MEDICAL CENTER 3533 PRAIRIEVIEW STREET GRAND ISLAND, NE 68803 |
Not Available |
|
MEMORIAL HOSPITAL 1423 SEVENTH ST AURORA, NE 68818 |
Not Available |
|
MERRICK MEDICAL CENTER/LITZENBERG MEMORIAL COUNTY HOSPITAL PO BOX 417, 2802 28TH ST CENTRAL CITY, NE 68826 |
Not Available |
|
HOWARD COUNTY MEDICAL CENTER P O BOX 406, 1113 SHERMAN ST ST PAUL, NE 68873 |
Not Available |
Medical Professionals Associated with Chi Health St Francis
These are the doctors who are affiliated with Chi Health St Francis. The data is from the most recent period. Historical data is not available.
- STEVEN HUSEN ( FAMILY PRACTICE - FAMILY PRACTICE OF GRAND ISLAND P C )
- JENNIFER BROWN ( INTERNAL MEDICINE - UNMC PHYSICIANS )
- TRAVIS HAGEMAN ( INTERNAL MEDICINE - UNMC PHYSICIANS )
- JAY ANDERSON ( INTERNAL MEDICINE - UNMC PHYSICIANS )
- ISAAC BERG ( INTERNAL MEDICINE - UNMC PHYSICIANS )
- KIMBERLY MICKELS ( INTERNAL MEDICINE - UNMC PHYSICIANS )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Chi Health St Francis
Five different rating results plus detailed inspection numbers and quality measures for Chi Health St Francis.
Covid Infections at Chi Health St Francis
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Chi Health St Francis
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Chi Health St Francis
A list of all of the registered owners for Chi Health St Francis. This includes direct and indirect owners and managers.
Noted Deficiencies for Chi Health St Francis
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Chi Health St Francis compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in GRAND ISLAND, NE
Homes that you should consider. A list ranking the best skilled nursing facilities in GRAND ISLAND based on their weighted inspection score as of May 01, 2023.
Worst Nursing Homes in GRAND ISLAND, NE
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in GRAND ISLAND based on their weighted inspection score as of May 01, 2023.
Other Data Periods:
Data on Chi Health St Francis is available for the following periods:
