Cycle 1
Health 2025-07-10 · Fire 2025-07-10
0 health deficiencies
No concentrated health issue counts in this cycle.
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Hebron, NE
Blue Valley Lutheran Nursing Home
4-star overall rating with 5-star inspections with 19 fire-safety deficiencies in the latest cycle
220 Park Avenue, Hebron, NE
(402) 768-3900
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,626
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 38.89% · Performance 62.16% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.62
Baseline 5.34 hours · Performance 4.39 hours · Measure score 4.62 · Achievement 4.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.26% |
8.2%
1.1 pts better
|
Numerator 5 · Denominator 54 |
| Staff flu vaccination coverage | 63.89% |
42%
21.9 pts better
|
Numerator 46 · Denominator 72 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 1.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
92.8%
5.5 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.9% · Q3 100.0% · Q4 96.4% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
96.1%
0.8 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.3% |
4.5%
3.8 pts worse
|
3.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.4% · Q3 10.0% · Q4 7.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.3%
3.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
19.5%
4.2 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 15.4% · Q3 8.3% · Q4 13.6% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.6% |
21.6%
9 pts worse
|
16.7%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 27.3% · Q3 28.6% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 11.6% |
0.3%
11.3 pts worse
|
0.1%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 12.5% · Q3 10.0% · Q4 14.3% · 4Q avg 11.6% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.3% |
20.4%
1.9 pts worse
|
16.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.6% |
19.9%
12.7 pts worse
|
14.9%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 41.7% · Q3 36.4% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.6%
About the same
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 2.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.9%
0.4 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.3% · Q4 7.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
26.6%
1.4 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.7% · Q2 28.4% · Q3 18.2% · Q4 34.5% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.3%
0.1 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.8% · Q3 7.4% · Q4 2.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.5% |
80.5%
26 pts worse
|
81.7%
27.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 54.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-26
F · Potential for more than minimal harm
2025-07-10
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-08-26
F · Potential for more than minimal harm
2024-06-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-05-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-12
E · Potential for more than minimal harm
2023-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
F · Potential for more than minimal harm
2023-05-25
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Chos, Doug
Operational/Managerial Control · Individual
Chos, Doug
Corporate Officer · Individual
Chos, Doug
W-2 Managing Employee · Individual
Wittler, Lori
W-2 Managing Employee · Individual
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#2
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#3
Heritage Care Center
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