01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-13 | 1 | 2025-03-13 | 4 |
| Cycle 2 | 2024-03-07 | 4 | 2024-03-07 | 2 |
| Cycle 3 | 2023-02-07 | 7 | 2023-02-07 | 21 |
CMS CCN 2853032026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
St Joseph'S Hillside Villa
540 E Washington Street · West Point, NE 68788 · Cuming County
Certified beds54CMS provider file
Recent citation rows39current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
39 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-13 · FIREE0020Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-13 · FIREE0035Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-13 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-13 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-13 · FIREK0925Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Correction field: Deficient, Provider has date of correction · 2025-03-272024-09-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-25 · complaint2024-03-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-07 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-07 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-07 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-07 · FIREK0922Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use and maintenance of medical gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-03-292023-02-07 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2023-02-242023-02-07 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · HEALTHF0881Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-07 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-03-152023-02-07 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-03-072023-02-07 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-03-072023-02-07 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-02-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HASS, BRIANIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 11/15/2018
- LOCH, TIMOTHYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 08/19/2020
- TROYER, AMYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 08/19/2020
- FALK, THERESAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/04/2017
- GRAYBEAL, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/04/2017
- LOCH, TIMOTHYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/19/2020
- REIMERS, BRIANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/04/2017
- ROSE, JOYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/04/2017
- STEFFENSMEIER, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/01/2018
- WHITE, DIANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/04/2017
- FALK, THERESAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/18/2017
- GRAYBEAL, MICHAELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/18/2017
- LOCH, TIMOTHYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/19/2020
- REIMERS, BRIANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/18/2017
- TROYER, AMYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/19/2020
- WHITE, DIANEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/18/2017
- FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/04/2017
- HOLY FAMILY CONVENT OF FRANCISCAN SISTERS OF CHRISTIAN CHARITY INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/04/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.34per resident day
RN hours0.98per resident day
Weekend nurse hours3.79per resident day
Staff turnover36.8%CMS reported field
06 / LOCAL RECORDS
Open the Nebraska ledger →Other published facilities nearby
No second facility in the same city met the directory rule.