Deficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 18
Capacity: 36
Deficiencies: 0
Oct 27, 2025
Visit Reason
The document is a hospital license renewal application and related certification for CHI Health St. Francis, verifying the facility's compliance and license renewal for the period 1/1/2026 to 12/31/2026.
Findings
The facility meets statutory requirements for licensing as a Long Term Care Hospital/Dual facility with a licensed capacity of 36 beds. The occupancy permit was issued on 3/18/2025 with no noted deficiencies or violations in the provided documents.
Report Facts
Licensed beds: 36
Beds occupied: 18
Renewal fee: 1750
Occupancy permit date: Mar 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Schieber | President | Administrator named in the renewal application. |
| Fr. Kevin FitzGerald | Board Chair | Authorized person signing the renewal application. |
| Kent Barney | Board Vice Chair | Authorized person signing the renewal application. |
| Mark Manchester | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Inspection Report
Renewal
Census: 14
Capacity: 36
Deficiencies: 0
Oct 11, 2024
Visit Reason
The document is a hospital license renewal application and related occupancy permit for CHI Health St. Francis, verifying licensure and renewal for the period 1/1/2025 to 12/31/2025.
Findings
The documents confirm that CHI Health St. Francis meets statutory requirements for licensure as a long term care hospital/dual facility with a licensed capacity of 36 beds. The occupancy permit was issued on 1/29/2024 and the census on 10/11/2024 was 14 residents.
Report Facts
Licensed Capacity: 36
Census: 14
Renewal Fee: 1750
Inspection Report
Renewal
Census: 34
Capacity: 36
Deficiencies: 0
Nov 26, 2019
Visit Reason
This document is related to the renewal of the hospital license for CHI Health St. Francis for the period 1/1/2020 to 12/31/2020.
Findings
The document confirms that CHI Health St. Francis meets statutory requirements for licensure as a Long Term Care Hospital/Dual facility. It includes details on licensed beds, occupancy, and corporate officers, with no deficiencies or violations noted.
Report Facts
Licensed beds: 36
Beds occupied: 34
License renewal fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Hannon | Administrator | Named as the facility administrator on the renewal application. |
| Jeanette M Wojtalewicz | CFO | Signed the renewal application as authorized person. |
| Kathy A Bressler | COO | Signed the renewal application as authorized person. |
| Cliff A. Robertson | Corporate President | Listed as corporate president on the renewal application. |
| Kathy Bressler | Corporate Vice President | Listed as corporate vice president on the renewal application. |
| Jeanette Wojtalewicz | Corporate Secretary | Listed as corporate secretary on the renewal application. |
Inspection Report
Complaint Investigation
Census: 18
Capacity: 36
Deficiencies: 9
Sep 23, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Chi Health St Francis on September 23-27, 2018, by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to have multiple deficiencies including failure to submit investigations within 5 working days, failure to provide written information on advance directives to residents, failure to report incidents of abuse timely, incomplete quarterly assessments, inadequate baseline care plans for pain management, incomplete medication regimen reviews documentation, medication labeling deficiencies, improper food handling practices, and failure to follow transmission-based precautions.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to submit investigations within 5 working days. The investigation revealed the facility investigated allegations but failed to submit reports timely, violating Federal tag F609 and State Licensure tag 175 NAC 12-006.02(8). Additional complaint-related deficiencies included failure to report abuse incidents timely and failure to provide advance directive information.
Severity Breakdown
SS=E: 6
SS=D: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to submit investigation reports within 5 working days to the State Agency. | — |
| Facility failed to provide written information on Advance Directives to 5 residents. | SS=E |
| Facility failed to report incidents of abuse to the State Agency within required timeframes. | SS=E |
| Facility failed to complete quarterly MDS assessment within required 92 days. | SS=D |
| Facility failed to develop baseline care plans addressing immediate healthcare needs of pain for 2 residents. | SS=E |
| Facility failed to document monthly medication regimen reviews in residents' medical records when no irregularities were found. | SS=E |
| Facility failed to ensure medication labels matched physician orders for 7 medications on 2 residents. | SS=E |
| Facility failed to serve food in a manner to prevent food borne illnesses; staff handled food with bare hands without hand hygiene. | SS=D |
| Facility failed to ensure transmission-based precautions were followed by staff for 2 residents in isolation. | SS=D |
Report Facts
Deficiencies cited: 9
Facility census: 18
Total capacity: 36
Pain rating: 5
Quarterly MDS assessment interval: 95
Pressure ulcer size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Hannon | Administrator | Named as facility administrator in the report. |
| Connie Vogt | RN, BSN, Program Manager | Signed the complaint investigation letter. |
| Theresa Jorgensen | Completed facility staffing form. |
Inspection Report
Routine
Census: 17
Capacity: 36
Deficiencies: 5
Aug 22, 2017
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including dignity and respect of residents, drug regimen review, infection control, and life safety code compliance.
Findings
The facility was found deficient in providing dignity and respect during personal care and catheterization, failed to ensure monthly drug regimen reviews for all residents, and had lapses in infection control practices including hand hygiene and sterile technique. Additionally, the facility lacked a complete fire safety and sprinkler system impairment policy and an adequate evacuation plan.
Severity Breakdown
SS=E: 1
SS=D: 2
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide dignity during personal cares and catheterization, including not covering residents and exposing personal information on white boards. | SS=E |
| Failure to ensure monthly drug regimen review by a licensed pharmacist for one resident. | SS=D |
| Failure to utilize proper infection control practices including hand hygiene, sterile technique during catheter insertion, and preventing cross contamination during wound care. | SS=D |
| Failure to provide a complete sprinkler system impairment policy including notification requirements and triggers for fire watch. | SS=F |
| Failure to provide a complete fire evacuation and relocation plan addressing evacuation order by proximity to fire and bariatric/special needs evacuation procedures. | SS=F |
Report Facts
Facility census: 17
Total licensed capacity: 36
Missing monthly pharmacy reviews: 3
Urinary tract infection rate: 3.8
Urinary tract infection rate: 8
Facility beds: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Named in findings related to dignity during catheterization and infection control breaches |
| DON | Director of Nursing | Interviewed regarding dignity expectations and monitoring staff compliance |
| Assistant Director of Nursing | ADON | Confirmed absence of monthly pharmacy reviews and infection control expectations |
| LPN | Licensed Practical Nurse | Coached on catheterization and wound care technique breaches |
| Facilities A | Facility Staff | Interviewed regarding fire watch policy and fire evacuation plan deficiencies |
Inspection Report
Life Safety
Census: 20
Capacity: 36
Deficiencies: 2
Jul 26, 2016
Visit Reason
The inspection was conducted to assess compliance with life safety code regulations, specifically related to fire protection and electrical safety in the facility.
Findings
The facility was found to be generally compliant with long term care regulations but had deficiencies related to fire alarm system inspection documentation and the use of non-hospital grade power strips in a resident room, which posed potential fire hazards.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to conduct fire alarm inspection/testing for all fire alarm system devices; inspection report lacked required details such as transmission type, device locations, serial numbers, device types, circuit types, and testing results. | SS=F |
| Use of non-hospital grade power strip in Resident Room 338 with non-medical equipment plugged in, violating CMS regulations and creating potential electrical fire hazard. | SS=D |
Report Facts
Facility census: 20
Licensed capacity: 36
Inspection Report
Renewal
Capacity: 36
Deficiencies: 0
Dec 15, 2015
Visit Reason
The document is a hospital licensure renewal application and related correspondence for CHI Health St. Francis, a long-term care hospital, to renew its license and maintain Medicare/Medicaid certification.
Findings
The documents confirm that CHI Health St. Francis meets statutory requirements for licensure as a long-term care hospital with a total licensed capacity of 36 beds. The renewal application was approved and the facility is in compliance with state licensure regulations.
Report Facts
Total licensed beds: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Mc Elligott | Administrator | Named as facility administrator in the renewal application |
| Diana Meyer | Program Manager | Signed correspondence regarding approval of licensure compliance |
| Richard L. Herink | Authorized Representative | Signed renewal application |
| Michael T. DeFreece | Authorized Representative | Signed renewal application |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
May 28, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Chi Health St Francis on May 26-28, 2015. The complaint allegations included insufficient staff to meet residents' needs, unattractive and unpalatable meals, and failure to answer call notification systems promptly.
Findings
The facility was found to have sufficient staff, meals were attractive and palatable, and call notification systems were answered promptly. However, deficiencies were identified including failure to develop comprehensive care plans addressing specific range of motion needs for a resident, failure to maintain food temperatures at safe levels, failure to assess and document the need and results of antianxiety medication administration, failure to conduct fire drills on all shifts quarterly, and failure to maintain emergency generator testing documentation.
Complaint Details
The complaint allegations were that the facility failed to have sufficient staff to meet residents' needs, failed to ensure meals were attractive and palatable, and failed to answer call notification systems promptly. The investigation found no violations related to these allegations.
Severity Breakdown
SS=D: 2
SS=F: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans to identify specific range of motion needs and interventions for one resident. | SS=D |
| Failure to maintain foods at a temperature to prevent potential growth of microorganisms, with food temperatures below recommended levels during service. | SS=F |
| Failure to assess the need for and document results of antianxiety medication administration for one resident. | SS=D |
| Failure to conduct fire drills quarterly on each shift as required by NFPA 101 Life Safety Code. | SS=F |
| Failure to maintain emergency generator testing documentation, specifically failure to record load pickup time within 10 seconds during monthly load testing. | SS=F |
Report Facts
Facility census: 22
Food temperatures: 132
Food temperatures: 120
Food temperatures: 130
Antianxiety medication administrations: 4
Fire drill times: 4
Facility census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan McElligott | Administrator | Named as facility administrator in complaint investigation letter |
| Christine Hale | Registered Nurse | Surveyor conducting complaint investigation |
| Daniel Woodward | Registered Nurse | Surveyor conducting complaint investigation |
| Dain Weiss | Registered Nurse | Surveyor conducting complaint investigation |
| Connie Heavin | Social Worker | Surveyor conducting complaint investigation |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed complaint investigation letter |
| Safety A | Interviewed staff regarding fire drills and generator testing | |
| Assistant Director of Nursing | Interviewed regarding medication documentation expectations | |
| Licensed Practical Nurse A | LPN | Interviewed about resident's range of motion needs |
| Nursing Assistant B | NA | Observed performing range of motion on resident |
| Dietary Associate C | DA | Interviewed about food temperature standards |
| Dietary Associate D | DA | Interviewed about food temperature monitoring |
| Director of Nutritional Services | Interviewed about food temperature monitoring and standards |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 4
Jun 19, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at St Francis Memorial Health Center on June 16, 2014-June 19, 2014, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility failed to prevent the potential for food borne illness due to inadequate dishwasher temperatures and bare hand contact with ready to eat food. The facility ensured residents were protected from abuse with no violations found. Additionally, the facility failed to separate a hazardous area from use areas in one smoke compartment and had electrical wiring issues in the dining room.
Complaint Details
The complaint allegation was that the facility failed to ensure residents are free from abuse. The investigation found the facility did ensure residents were protected from abuse with no violations.
Deficiencies (4)
| Description |
|---|
| Failed to ensure dishwasher temperatures met manufacturer's recommendations, risking food borne illness. |
| Staff had bare hand contact with ready to eat food, violating food safety protocols. |
| Failed to separate a hazardous area from use areas in one of two smoke compartments, risking smoke and fire migration. |
| Electrical wiring in the dining room was not in accordance with NFPA 70; junction box lacked cover. |
Report Facts
Facility census: 17
Facility census: 22
Residents affected: 4
Residents affected: 9
Residents affected: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan McElligott | Administrator | Facility administrator addressed in complaint investigation letter |
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Travis Castner | Registered Nurse | Surveyor involved in complaint and annual survey |
| Christine Hale | Registered Nurse | Surveyor involved in complaint and annual survey |
| Daniel Woodward | Registered Nurse | Surveyor involved in complaint and annual survey |
| Connie Heavin | Social Worker | Surveyor involved in complaint and annual survey |
| Dietary Manager | Confirmed dishwasher gauge malfunction and acknowledged temperature issues | |
| Director of Nursing | Confirmed staff training on no bare hand contact with ready to eat food | |
| Safety A | Acknowledged fire safety door and electrical wiring deficiencies |
Inspection Report
Routine
Census: 21
Deficiencies: 1
Mar 26, 2013
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, as well as compliance with the Life Safety Code.
Findings
The facility was found to have a deficiency related to the failure to develop comprehensive care plans with measurable goals and timeframes for residents, specifically Resident 2 regarding range of motion services. The facility was in compliance with the Life Safety Code at the time of inspection.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans for Resident 2 related to range of motion services, lacking measurable goals and timeframes. | SS=D |
Report Facts
Facility census: 21
Residents sampled: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Interviewed regarding lack of detail in care plan for Resident 2 |
| RN-B | Registered Nurse | Interviewed regarding lack of detail in care plan for Resident 2 |
| Nursing Assistant C | Interviewed about range of motion services provided to Resident 2 |
Inspection Report
Annual Inspection
Census: 21
Deficiencies: 7
Nov 30, 2011
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations governing skilled nursing facilities, including medication management, infection control, and life safety code standards.
Findings
The facility was found deficient in multiple areas including failure to taper sedative/hypnotic medication as recommended for one resident, inadequate infection control practices related to laundry water temperature and whirlpool tub sanitization, failure to maintain fire safety measures such as one-hour fire separation in exit stairs, emergency lighting, sprinkler system maintenance, and lack of flame retardant documentation for curtains.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to attempt dose reduction of sedative/hypnotic medication beyond manufacturer's recommended duration for one resident. | SS=D |
| Failure to maintain an effective infection control program including laundering personal clothing at adequate water temperature and sanitizing whirlpool tub properly. | SS=E |
| Failure to provide one hour fire separation in one of three exit stairs, allowing potential smoke and fire entry. | SS=E |
| Failure to maintain battery backup emergency lighting in mechanical spaces. | SS=D |
| Failure to label fire department connections properly. | SS=F |
| Failure to maintain sprinkler system including missing escutcheon rings and insufficient spare sprinkler heads. | SS=F |
| Failure to provide documentation that curtains throughout the facility were flame retardant. | SS=F |
Report Facts
Facility census: 21
Residents affected by fire exit deficiency: 13
Facility capacity: 36
Medication dose duration: 332
Number of residents sampled: 10
Number of residents using laundry services: 7
Facility census for fire safety: 26
Number of missing spare sprinkler heads: 4
Inspection Report
Follow-Up
Census: 21
Deficiencies: 2
Dec 16, 2010
Visit Reason
The visit was a follow-up survey to assess the facility's compliance with infection control and catheterization practices, specifically addressing deficiencies related to urinary tract infection prevention and whirlpool tub disinfection.
Findings
The facility was found deficient in preventing urinary tract infections by improper catheterization and inadequate perineal care for residents, as well as failure to properly disinfect the whirlpool tub, posing infection risks. The facility provided plans for corrective actions including staff training, competency testing, and monitoring.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents without indwelling catheters were not catheterized unless clinically necessary and inadequate perineal care leading to potential urinary tract infections. |
| Failure to establish and maintain an infection control program to prevent spread of infection, including improper disinfection of whirlpool tub after use. |
Report Facts
Facility census: 21
Sample size: 10
Residents with urinary tract infections: 3
Urine culture colony count: 100000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Jorgensen | Director of Skilled Nursing | Signed plan of correction addendum and responsible for monitoring staff compliance |
Notice
Capacity: 36
Deficiencies: 0
APP2023
Visit Reason
This document serves as the hospital license renewal application for the period 1/1/2023 to 12/31/2023 and includes verification of licensure and occupancy permit for CHI Health St. Francis.
Findings
The document confirms that CHI Health St. Francis meets statutory requirements for licensure as a Long Term Care Hospital/Dual facility with a licensed capacity of 36 beds and includes an occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Licensed Capacity: 36
Renewal Period: 2023
Number of Licensed Beds: 36
Renewal Fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hannon | President | Administrator named in renewal application |
| Maurita Soukup | Corporate President | Corporate officer listed in ownership information |
| Bill Yates | Corporate Vice President | Corporate officer listed in ownership information |
| Kevin FitzGerald | Corporate Secretary | Corporate officer listed in ownership information |
| William Barney | Corporate Treasurer | Corporate officer listed in ownership information |
| Mark Manchester | Deputy State Fire Marshal | Approved occupancy permit |
Notice
Capacity: 36
Deficiencies: 0
APP2024
Visit Reason
This document serves as the hospital license renewal application for CHI Health St. Francis for the period 1/1/2024 to 12/31/2024, including verification of licensure and occupancy permit.
Findings
The facility is licensed as a Long Term Care Hospital/Dual with 36 licensed beds and meets statutory requirements for licensure through 12/31/2024. An occupancy permit was issued on 3/14/2023 by the State Fire Marshal.
Report Facts
Licensed beds: 36
Renewal period: License renewal period from 1/1/2024 to 12/31/2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Hannon | President | Administrator and preferred contact for official notices. |
| Maurita Soukup | Corporate President | Signed renewal application as authorized person. |
| William Yates | Corporate Vice President | Signed renewal application as authorized person. |
Notice
Capacity: 36
Deficiencies: 0
APP2017
Visit Reason
This document set serves to notify and confirm the renewal of the license for CHI Health St. Francis long term care hospital, verify deemed status for licensure based on Medicare/Medicaid certification, and provide occupancy permit details.
Findings
The documents confirm that CHI Health St. Francis meets statutory requirements for licensure as a long term care hospital with a licensed capacity of 36 beds. The facility is deemed in compliance with state licensure regulations based on Medicare/Medicaid certification, and holds a valid occupancy permit for 36 beds.
Report Facts
Licensed Capacity: 36
Occupancy Permit Date: 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Schneiders | Administrator / Hospital President | Named as Administrator and Hospital President effective November 21, 2016 |
| Diana Meyer | Program Manager, Office of Acute Care Facilities | Signed approval letter for deemed status compliance |
| Dan McElligott | Administrator | Former Administrator, last day November 23, 2016 |
| Kimberly Sorensen | Right Track Coordinator | Sent notification letter regarding administrator change |
Notice
Capacity: 36
Deficiencies: 0
APP2018
Visit Reason
This document serves as a licensure renewal application and verification of licensure for CHI Health St. Francis, including occupancy permit and bed capacity information.
Findings
The documents confirm that CHI Health St. Francis is licensed as a Skilled Nursing Facility with a total licensed capacity of 36 beds. The occupancy permit was issued on 2016-07-26, and the renewal application was submitted for license expiration on 2017-12-31.
Report Facts
Licensed Capacity: 36
Occupancy Permit Date: Jul 26, 2016
Notice
Capacity: 36
Deficiencies: 0
APP2019
Visit Reason
This document serves as the hospital license renewal application for CHI Health St. Francis for the renewal period January 1, 2019 to December 31, 2019.
Findings
The document includes provider and ownership information, renewal fees, required signatures, and an occupancy permit indicating the facility has 36 licensed beds.
Report Facts
Number of licensed beds: 36
Renewal fee amount: 1750
Total payment amount: 9850
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ed Hannon | Hospital President / Administrator | Named as the preferred person to receive official notices and as the administrator. |
| Cliff A. Robertson | Corporate President | Listed as Corporate President and signer of the renewal application. |
| Jeanette Wojtalewicz | Corporate Secretary / Treasurer | Listed as Corporate Secretary / Treasurer and signer of the renewal application. |
| Kathy Bressler | Corporate Vice President | Listed as Corporate Vice President. |
Notice
Census: 33
Capacity: 36
Deficiencies: 0
APP2021
Visit Reason
This document serves as a hospital license renewal application for the period 1/1/2021 to 12/31/2021 and includes an occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The documents confirm that CHI Health St. Francis meets statutory requirements for licensure as a long term care hospital/dual facility with a licensed capacity of 36 beds. The occupancy permit issued on 2/21/2020 approves a maximum occupancy of 36 beds.
Report Facts
Licensed beds: 36
Beds occupied: 33
Renewal period: 365
Renewal fee: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward J. Hannon | Hospital Administrator | Named as hospital administrator in the renewal application. |
| Cliff A. Robertson | Corporate President, M.D. | Named as corporate president and authorized signer on renewal application. |
| Jeanette Wojtalewicz | Corporate Secretary and Treasurer | Named as corporate secretary and treasurer and authorized signer on renewal application. |
| Mark Manchester | Deputy State Fire Marshal | Inspected the facility and issued the occupancy permit. |
Notice
Capacity: 36
Deficiencies: 0
APP2022
Visit Reason
This document serves as a hospital license renewal verification and includes related corporate and ownership information for CHI Health St. Francis for the renewal period 1/1/2022 to 12/31/2022.
Findings
The document confirms that CHI Health St. Francis meets statutory requirements for licensure as a Long Term Care Hospital/Dual and provides details on licensed bed capacity, corporate officers, and board of directors. It includes an occupancy permit and renewal application information.
Report Facts
Licensed Capacity: 36
License Renewal Period: January 1, 2022 to December 31, 2022
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