Provider Name: CHI HEALTH ST FRANCIS
Address: 2116 WEST FAIDLEY AVENUE, GRAND ISLAND, NE 68803
Phone: (308) 398-5880
County: Hall (390)
Ownership Type: Non profit - Corporation
Certified Beds: 36
Average Residents Per Day: 15.4 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: SAINT FRANCIS MEDICAL CENTER
First Approved Date: August 20, 1987
Affiliated Entity: CHI LIVING COMMUNITIES (139)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 4 ()
Long Stay QM Rating: 2 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 3.63290, LPN Staff Hours Per Day: 0.3259, RN Staff Hours Per Day: 3.3081, Licensed Staff Hours Per Day: 3.6341
Total Nurse Staff Hours Per Day, per resident: 7.26702
Weekend Nurse Staff Hours: 6.27000, Weekend RN Staff Hours: 2.2623
PT Staff Hours Per Day, per resident: 0.4406
Nurse Staff Turnover: 40.0, Nurse Turnover Note:
RN Turnover: 42.9, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 2.1973, Case Mix LPN Hours Per Day: 0.8838, Case Mix RN Hours Per Day: 0.4925
Adjusted Nurse Aide Hours Per Day, per resident: 3.36821, Adjusted LPN Hours Per Day: 0.2721, Adjusted RN Hours Per Day: 2.5309
Total Adjusted Nurse Hours Per Day, per resident: 6.40961
Adjusted Weekend Nurse Hours Per Day, per resident: 5.53023
Health Survey Dates and Scores: Cycle 1: 2024-02-01 (Score: 24), Cycle 2: 2023-03-13 (Score: 24), Cycle 3: 2021-11-15 (Score: 16)
Total Weighted Health Score: 22.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 10405.14, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 2116 WEST FAIDLEY AVENUE,GRAND ISLAND,NE,68803 (40.9242, -98.364)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-15
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-21
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-03-15
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-20
Type: Health, Deficiency: Have enough outside ventilation via a window or mechanical ventilation, or both.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-20
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-07
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-07
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0223, Version: New
Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-02-22
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2024-02-22
Type: Fire Safety, Tag: 0921, Version: New
Description: Ensure that testing and maintenance of electrical equipment is performed.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-20