Faith Health
An acute care hospital in Norfolk, Nebraska 68701
2700 West Norfolk Ave, Norfolk, Nebraska 68701. (402) 371-4880.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 1 deficiency cited in the last three years
- 133 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Dec 17, 2025: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Oct 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Oct 30, 2024: complaint inspection1 deficiency
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Rn Supervision Of Nursing Care
The inspectors’ words, 784 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 16132 Based on facility policy and procedure review, medical record review, and staff interviews, the facility failed to ensure adequate supervision by nursing to perform and document an assessment of a coccyx (tailbone) for 1 of 3 sampled patients with wounds (Patient 6) from a sample of 11. This failed practice had the potential to affect all patients of the hospital. On 10/24/2024 the inpatient census was 81. Findings are: A. Review of the facility policy titled Pressure Injury Prevention/Wound Care Protocol (Last approved 5/2024) revealed: ...”all wounds are documented with assessments to include: -Location -Size (length, width, depth) -Characteristics, and appearance of the wound to include tunneling or undermining. -Characteristics of the skin around the wound. -Drainage characteristics and amount. -Document wound assessments and treatments with each dressing change in the EHR (electronic health record). -On consulted inpatients, the wound nurse will see the patient weekly to measure, assess, apply dressing, and document wounds in the EHR. The wound nurse will partner with floor nursing staff for this dressing change to ensure understanding of dressing changes throughout the week.” B. Review of Patient 6’s medical record (10/29/2024) revealed the patient was admitted on 10/15/2024 from a nursing home for a left foot infection. Review of the 10/15/2024 History and Physical, identified the diagnosis to included “severe sepsis (blood infection) secondary to a complicated left foot infection, diabetes, hypertension (high blood pressure, depression, peripheral artery disease.)” -Review of Patient 6’s coccyx wound orders and flowsheet documentation identified the following: 1) That upon admission on 10/15/24 the admission registered nurse (RN) did a head-to-toe assessment of the patient’s skin. That assessment revealed a gluteal cleft (coccyx) wounds. 2) On 10/15/24, the admission RN requested a wound care consult. The physician order dated 10/15/25 at 2:08 PM “Inpatient consult to Wound Care Nurse Other, Pressure ulcer; left foot wound, COCCYX PU (pressure ulcer), left foot wound.” 3) Review of the initial wound integrity flowsheet dated 10/15/24 at 12:28 PM identified “3 small S2 (stage 2-a shallow open sore with a red or pink wound bed) areas < (less than) 2 cm (centimeter)”. The flowsheet identified the Peri-wound (skin surrounding open area) Assessment - Erythema (red); wound bed color “pink”; no drainage; cleansed and left open to air. 4) Review of the wound integrity flowsheet (documented every 4 hours) identified 10/16/24 at 11:05 AM identified peri-wound; wound bed and wound drainage as: UTA (unable to assess) and open to air. On 10/16/24 at 11:10 AM the documentation identified peri-wound: Erythema; bleeding due to taking brief off and ripping off a scab. 5) Review of the every 4 hour wound integrity flowsheet documentation from 10/16/24-10/26/24 identified the peri-wound area as erythema; wound bed color as pink/red/or UTA; and open to air. The every 4-hour documentation from 10/15/25 12:28 AM-10/26/24 at 7:38 AM lacked measurements or description of the progress of the wound. 6) Review of the wound integrity flowsheet 10/26/24 at 7:58 PM -10/30/24 identified the peri-wound area and wound bed color as UTA; and covered with a Mepilex (a foam dressing). These assessments lacked measurements or a description of the progress of the wound. -Review of the Wound Nurse Consult (RN-W) documentation dated 10/28/2024 at 5:01 PM stated, “Pt seen for assessment of wound to coccyx. Pt has an unstageable pressure injury to the coccyx. This has been covered with a foam border.” “Patient would benefit from an EHOB mattress overlay (an air-filled mattress placed on bed) for pressure reduction and will need to follow up outpatient for wound care for the coccygeal pressure injury. Wound Care will follow up with patient weekly during hospital stay.” C. Interview with RN-W (10/30/2024 at 10:12 AM) revealed, “I went to the floor and looked at it on 10/28/24.” When inquired why it wasn’t assessed prior to that when the 10/15/2024 physician order was placed, RN-W replied, “I just saw it, it was on my list, and I missed it when it was ordered.” “Not sure how that happened.” When asked where the measurements were documented, RN-W replied, “I lost them, so I didn’t get them documented.” When inquired if the reason the wound was described as an unstageable pressure injury if it was covered with an eschar (Leathery area on wound bed), RN-W replied, “No, it was covered in yellow slough (a fibrinous tissue that is formed by dead cells and/or bacteria in a wound). -Interview with RN-A (10/30/2024 at 12:30PM) confirmed RN-W’s 10/28/2024 5:01PM wound consult note lacked evidence of measurements, characteristics, and appearance of patient 6’s coccyx pressure injury.”
All 4 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 17, 2025 | Complaint inspection | No deficiencies cited |
| Dec 11, 2024 | Complaint inspection | No deficiencies cited |
| Oct 30, 2024 | Complaint inspection | 1 deficiency cited |
| Dec 7, 2023 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 8; safety of care, 0 better and 0 worse of 3; readmission, 1 better and 0 worse of 8.
- Patients rate it 4 of 5 in CMS’s patient survey (436 surveys completed, Oct 1, 2024 to Sep 30, 2025): 72% rated it 9 or 10 out of 10, and 69% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 12.8%, heart failure 11%, pneumonia 17.5%, COPD 9.2%, stroke 9.3%, heart bypass surgery 2.5%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14%, heart failure 20.6%, pneumonia 16.9%, COPD 19.7%, heart bypass surgery 10.7%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 101 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
- 74% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.98 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Oct 1, 1996.
- Ownership: voluntary non-profit - church.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 7 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Church.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 93% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Lutheran Community Hospital Association of Norfolk Nebraska runs it.
- 29 owners or officers are people: Brent J Berner (corporate director); John B Dinkel (corporate officer); John B Dinkel (corporate director); Diane E Becker (corporate officer); Diane E Becker (corporate director); Mark W Davis (managing employee (on the payroll)); Mark W Davis (runs it (operational or managerial control)); Kelly A Driscoll (corporate officer); Kelly A Driscoll (managing employee (on the payroll)); Kelly A Driscoll (runs it (operational or managerial control)); Shawn D Beaudette (corporate director); Steffan R Lacey (corporate director); Roseanne M Brock (corporate director); Michael P Moreno (corporate director); Maryanne Hartzell (corporate director); Regina F Busboom (corporate director); Brenda Baker (corporate officer); Brenda Baker (managing employee (on the payroll)); Brenda Baker (runs it (operational or managerial control)); Lane T Handke (corporate director); Jason S Doele (corporate director); Joshua P Gossman (corporate director); Thomas Schueth (corporate officer); Thomas Schueth (corporate director); Leon G Rosenthal (corporate director); Connie Rupp (managing employee (on the payroll)); Connie Rupp (runs it (operational or managerial control)); Jacque L Collison (corporate officer); Jacque L Collison (corporate director).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- No other hospital CMS lists is in Madison County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.