CHI Health St. Francis

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

68.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · F2025-03-20 · tag F0729 — widespread
  Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a) The facility failed to verify that the Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) check was completed for 1 out of 10 Nursing Assistant (NA-A) sampled staff employees files. This had the potential to affect all 15 residents in the facility. Findings are: A record review of NA-A employee file revealed that the Nebraska Central Registry (Maintains all reports of child abuse and neglect opened for investigation, classified as either Court Substantiated or Agency Substantiated) with the following reason: -Notary needed A record review of NA-A work schedule revealed that NA-A worked the floor on: 3/13/25 3/14/25 3/15/25 3/17/25 3/18/25 3/19/25 An interview on 3/20/25 at 10:13 AM with the Administrator confirmed that NA-A did not have the Nebraska Central Registry check completed. The Administrator confirmed that NA-A should not have been working the floor prior the Nebraska Central Registry being completed and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-20 · tag F0625 — isolated
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify/provide the resident/resident's legal representative of the bed hold policy at the time of the transfer to the hospital and failed to provide written documentation of the bed hold policy to the legal representative for one (Resident 16) of 8 sampled residents. The facility's census was 15. Findings are: A closed record review revealed that Resident 16 was admitted to the facility on [DATE]. Resident 16 was admitted to the hospital on [DATE]. A review of the care notes revealed no documentation of a bed-hold policy being given to Resident 16 or Resident 16 family representative at time of transfer. Findings are: A record review of the undated facility's Transfer Process Policy revealed: -Put patient on LOA (Leave of Absence) in electronic health record. -If admitted to hospital, discharge from system unless they are Medicaid, then leave on LOA for bedhold. An interview on 3/18/25 at 2:30 PM with Social Service worker (SW) confirmed that the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-02-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review the facility failed to ensure items stored in the facility's refrigerators and freezers were sealed, labeled, and dated, ensure expired items were discarded, ensure kitchen staff performed handwashing for at least 20 seconds, and failed to ensure the temperature of the food was taken after being reheated in the microwave to prevent the potential for foodborne illness, and failed to ensure the thermometer probe was sanitized before use and between food items when the temperature was taken of the prepared food to prevent cross contamination. This had the potential to affect 15 of the 16 residents that consumed food from the kitchen. The total facility census was 16. Findings are: A. A record review of the facility's Food Supply and Storage policy with an origination date of 11/2012 revealed the staff should use approved storage containers for food, cover tightly, and label and date the containers in the refrigerator. Staff should date and rotate food items in the refrigerator, discard by…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-01 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to notify the provider of a significant weight loss for 1 (Resident 70) of 2 sampled residents. The facility identified a census of 16. Findings Are: A record review of Resident 70's demographic information printed on 1/30/24 revealed Resident 70 admitted into the facility on 1/13/24. The demographic information revealed Resident 70 had diagnoses of: Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus), Congestive Heart Failure (CHF- a serious condition in which the heart doesn't pump blood as efficiently as it should) exacerbation, and Acute on Chronic heart failure and Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). A record review of Resident 70's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/25/24, revealed the resident's cognitive status was answered as not assessed/no information. The MDS revealed Resident 70 was independent with eating…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-01 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to perform hand hygiene and gloves changes between completing J-tube site cares, medication administration and oral suctioning for Resident 4, and the facility failed to clean or change Resident 3's nebulizer kit and mask to prevent the potential for cross contamination. The facility identified a census of 16. Findings Are: A. A record review of the demographic information revealed Resident 4 had been accepted into the facility on 5/1/20 with a primary diagnosis of a gunshot wound to the head with complications. A record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 1/25/24, revealed the resident was in a persistent vegetative state/no discernible consciousness. The MDS revealed Resident 4 was dependent for all cares including toileting, bathing, repositioning, and enteral…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-03-13 · tag F0923 — widespread
  Have enough outside ventilation via a window or mechanical ventilation, or both.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-007.04D Based on observations, record review, and interview the facility failed to ensure that bathroom exhaust vent fans were operational in 16 of 16 occupied rooms. This affected all facility residents. The facility census was 16. Findings are: Record review of the facility admission Agreement Resident Rights dated 2016 revealed that the nursing facility must provide a safe, clean, comfortable, and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 3/7/23 at 9:36 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper (indicating that the vent was not operating). A strong odor of bowel movement (BM) was present. Observation on 3/7/23 at 9:38 AM in room [ROOM NUMBER] revealed that the bathroom vent fan would not suck up a 1 ply square of toilet paper. Observation on 3/7/23 at 9:40 AM in room [ROOM NUMBER]…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-03-13 · tag F0655 — pattern
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09C1a Based on record review and interview the facility failed to ensure that the resident /resident representative received a written summary of the preliminary care plan (either the baseline or the comprehensive care plan) (a written initial plan of care required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) as required for 5 residents (Residents 66, 11, 69, 5, and 13) of 5 residents reviewed. This prevented the resident/resident representative from identifying additional areas of care required. The facility census was 16. Findings are: A. Record review of the facility policy titled Comprehensive Care Planning dated 2/2018 revealed that the purpose is to fulfill state and federal regulations for long term care and to focus on the resident's ability to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Record review of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in NE