Map showing the location of St Joseph's Hillside Villa in West Point, Nebraska
540 E Washington Street, West Point, NE, 68788

Overall Score

CMS Five-Star Quality Rating
5/5Much above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • NebraskaAbove 82% of peers178 rated homes · average 2.9★
  • United StatesAbove 80% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point4★+1.2 vs NE avg
  • StaffingCan add or remove a star5★+1.6 vs NE avg
  • Quality measuresCan add or remove a star3★±0.0 vs NE avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles4★Above 66% of peersNE avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 81% of peersNE avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 37% of peersNE avg3.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.57hrsAbove 74% of peersNE avg4.17Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.98hrsAbove 87% of peersNE avg0.71Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better46%Above 54% of peersNE avg49%RN turnover33%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 25% of peersNE avg$10,100Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
16citations
6inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Mar 13, 2025most recent

Citations by monthFeb 2023 – Mar 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Mar 13, 20251 citationCycle 1worst D · no actual harm
  1. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Mar 27, 2025
Sep 10, 20241 citationCycle 2worst D · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 25, 2024
Mar 7, 20243 citationsCycle 2worst D · no actual harm
  1. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 29, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 29, 2024
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 29, 2024
Apr 24, 20232 citationsCycle 3worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 12, 2023
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 12, 2023
Mar 15, 20232 citationsCycle 3worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 7, 2023
  2. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 7, 2023
Feb 7, 20237 citationsCycle 3worst E · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Mar 1, 2023
  2. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Mar 1, 2023
  3. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Mar 1, 2023
  4. F758Implement 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.Pharmacy ServiceE · patternCorrected Mar 1, 2023
  5. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected Mar 1, 2023
  6. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 1, 2023
  7. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 1, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.57hrsAbove 74% of peers+0.40 vs NE avg
  • Registered nursesRN hours only0.98hrsAbove 87% of peers+0.27 vs NE avg
  • Licensed practical nursesLPN hours0.42hrs
  • Nurse aidesCNA hours3.17hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.02hrs
  • Nebraska average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better46%Above 54% of peersNE avg 49%
  • RN turnoverRegistered nurses only33%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy54 certified beds · ~52 residents a day96%Top 3%NE avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $10,100NE avg in fines
Above only 25% of peersFewer fines than 25% of rated homes in Nebraska

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Nebraska facilities average 0.6 penalties.

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Independent
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Operational or managerial control
  • Franciscan Sisters of Christian Charity Sponsored Ministries, INC.
  • Holy Family Convent of Franciscan Sisters of Christian Charity INC
  • Brian Hass
  • Timothy Loch
  • Amy Troyer
Corporate directors
  • Theresa Falk
  • Michael Graybeal
  • Timothy Loch
  • Brian Reimers
  • Joy Rose
  • David Steffensmeier
  • Diane White
Corporate officers
  • Theresa Falk
  • Michael Graybeal
  • Timothy Loch
  • Brian Reimers
  • Amy Troyer
  • Diane White
Contracted managers
  • Brian Hass
Managing employees
  • Timothy Loch
  • Amy Troyer

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 285303 · 540 E Washington Street, West Point, NE, 68788.
  • Percentiles compare this facility with every rated nursing home in Nebraska and Cuming County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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