Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Norfolk, NE
Heritage of Bel Air
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1203 North 13th Street, Norfolk, NE
(402) 371-4991
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vetter Senior Living
Operator or chain grouping
Approved since
1989-05-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
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
0.63
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.12
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
995
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0163
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.83
Baseline 17.08% · Performance 18.27% · Measure score 6.83 · Achievement 6.83 · Improvement 0
Healthcare-associated infections
2.98
Baseline 7.43% · Performance 6.94% · Measure score 2.98 · Achievement 2.98 · Improvement 1.51
Total nurse turnover
8.24
Baseline 36.75% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 5.17
Adjusted total nurse staffing
6.44
Baseline 4.77 hours · Performance 4.91 hours · Measure score 6.44 · Achievement 6.44 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.07% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 0.93% · Lower 95% interval 5.42% |
| Discharge to community | 38.86% |
50.57%
11.7 pts worse
|
Worse than the National Rate · Eligible stays 93 · Observed rate 35.48% · Lower 95% interval 29.47% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 28.3% |
53.69%
25.4 pts worse
|
Numerator 15 · Denominator 53 |
| Discharge mobility score | 22.64% |
50.94%
28.3 pts worse
|
Numerator 12 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 0.92% |
8.2%
7.3 pts worse
|
Numerator 2 · Denominator 217 |
| Staff flu vaccination coverage | 12.08% |
42%
29.9 pts worse
|
Numerator 29 · Denominator 240 |
| Discharge function score | 28.3% |
56.45%
28.2 pts worse
|
Numerator 15 · Denominator 53 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 8 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
96.1%
2.9 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
4.5%
0.6 pts better
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.3% · Q3 4.6% · Q4 3.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.4%
4.1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.3%
1.9 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 9.8% · Q3 5.0% · Q4 6.2% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
19.5%
2.5 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 17.1% · Q3 16.2% · Q4 16.9% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
21.6%
17.2 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.3% · Q3 4.4% · Q4 5.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 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 whose ability to walk independently worsened | 15.3% |
20.4%
5.1 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.5% · Q3 6.9% · Q4 10.0% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
19.9%
10.2 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 15.4% · Q3 7.8% · Q4 5.0% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.9%
2.1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
26.6%
3.3 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 19.1% · Q3 21.3% · Q4 19.9% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.3%
3.3 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
80.5%
19 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.6%
4.9 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.7% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.4%
0.8 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 3.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
75.9%
20.3 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.3% |
20.9%
11.6 pts better
|
23.9%
14.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 7.5% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-30 · Fire 2024-07-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-25 · Fire 2023-07-25
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
D · Potential for more than minimal harm
2024-07-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-09
D · Potential for more than minimal harm
2023-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-31
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 2025-09-08
E · Potential for more than minimal harm
2025-07-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
D · Potential for more than minimal harm
2024-07-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
G · Actual harm
2023-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-22
Penalties and ownership
What sits behind the stars
Ownership
Vetter Senior Living
5% Or Greater Direct Ownership Interest · Organization
Hirschman, Bryon
Operational/Managerial Control · Individual
Hirschman, Bryon
Contracted Managing Employee · Individual
Stuhr, Brian
Operational/Managerial Control · Individual
Stuhr, Brian
Corporate Officer · Individual
Stuhr, Brian
Contracted Managing Employee · Individual
Vanekeren, Glenn
Operational/Managerial Control · Individual
Vanekeren, Glenn
Corporate Officer · Individual
Vanekeren, Glenn
Contracted Managing Employee · Individual
Vetter Senior Living
Operational/Managerial Control · Organization
Vetter, Eldora
Operational/Managerial Control · Individual
Vetter, Eldora
Corporate Officer · Individual
Vetter, Eldora
Contracted Managing Employee · Individual
Vetter, Jack
Operational/Managerial Control · Individual
Vetter, Jack
Corporate Officer · Individual
Vetter, Jack
Contracted Managing Employee · Individual
Vsl Vetter Health Services LLC
Operational/Managerial Control · Organization
Zamora, Tracy
Operational/Managerial Control · Individual
Zamora, Tracy
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
St. Joseph's Rehabilitation and Care Center
Norfolk, NE
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Community Pride Care Center
Battle Creek, NE
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Accura HealthCare of Pierce
Pierce, NE
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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