Inspection Reports for Blue Valley Lutheran Nursing Home
220 Park Avenue, HEBRON, NE, 68370
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
48% occupied
Based on a February 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certification for Blue Valley Lutheran Nursing Home, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The documents confirm that Blue Valley Lutheran Nursing Home meets statutory requirements for licensure renewal, including certification of services and occupancy permit. No deficiencies or violations are noted.
Report Facts
Total licensed beds: 64
Renewal license fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Grimes | Interim Administrator | Named on the renewal application as administrator |
| Danita Chambers | Director of Nursing, RN DON | Named on the renewal application as director of nursing |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 28, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Blue Valley Lutheran Nursing Home on June 28, 2019, regarding allegations that the facility failed to employ clinically qualified nutritional staff and failed to provide meals at ordered consistencies.
Complaint Details
The complaint alleged failure to employ clinically qualified nutritional staff and failure to provide meals at ordered consistencies. Both allegations were found to be unsubstantiated with no violations.
Findings
The investigation found that the facility employed qualified nutritional staff and provided meals at ordered consistencies, with no violations identified and the facility in compliance with regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
Notice
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
The document serves as a Notice of Disciplinary Action placing Blue Valley Lutheran Nursing Home on probation for 90 days starting March 21, 2019, due to violations of licensure regulations related to environmental safety and accident prevention.
Findings
The facility failed to provide adequate supervision to prevent falls with injury, maintain resident assisted devices, and follow care planned fall interventions. Multiple regulatory violations were identified and incorporated by reference from a CMS-2567 report dated March 6, 2019.
Report Facts
Probation period days: 90
Report submission frequency: 14
Notice finalization date: Mar 21, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager | Contact person for submission of reports and responses related to the disciplinary action |
| Linda Stenvers | Staff Assistant II | Certified service of the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Certificate of Service for the Notice |
| Bo Botelho | Interim Director, Division of Public Health | Signed the Notice of Disciplinary Action |
Inspection Report
Annual Inspection
Census: 31
Capacity: 64
Deficiencies: 19
Date: Feb 7, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Blue Valley Lutheran Nursing Home on February 3, 2019-February 7, 2019, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The visit was complaint and annual survey related. Resident Council complaints included issues with call light response times, food temperature, staff identification, and fresh water availability. The facility failed to timely report abuse allegations and failed to investigate some complaints.
Findings
The facility was found to be in compliance with medication administration, sedation, and bowel protocol. Deficiencies were identified in resident dignity during dining, resident council complaint follow-up, safe environment due to marred bathroom doors, failure to identify potential abuse, failure to train new employees on abuse policy, failure to report abuse allegations timely, inaccurate MDS coding for PASRR Level II diagnosis, failure to coordinate PASARR and assessments, failure to revise care plans after incidents, failure to maintain food temperatures, sanitation issues in kitchen and dining, failure to maintain bed safety, failure to ensure staff identification, failure to maintain adequate staffing and timely call light response, and fire safety code violations including egress door locking and fire door inspections.
Deficiencies (19)
Facility staff failed to treat residents with dignity during dining by not wearing gloves properly and not serving all residents at the same time.
Facility staff failed to address and resolve Resident Council complaints regarding fresh water, staff identification, food temperature, and call light response.
Facility failed to provide a homelike environment due to marred bathroom doors in 3 sampled residents' rooms.
Facility failed to identify situations as potential abuse and failed to report abuse allegations timely for 2 residents.
Facility failed to train new employees on abuse policy.
Facility failed to ensure medication labels matched physician orders for 3 residents.
Facility failed to ensure residents received fresh water routinely.
Facility failed to ensure sufficient nursing staff to answer call lights timely and prevent residents from being left on the toilet for extended periods.
Facility failed to post nurse staffing information daily with all required information.
Facility failed to serve drinks in the dining room to prevent cross contamination and failed to maintain kitchen sanitation including clean and dated spices, clean metal carts, and proper dish storage.
Facility failed to implement routine preventative maintenance to inspect all bed frames, mattresses, and bed rails for possible entrapment.
Facility failed to ensure residents could readily identify staff members due to staff not wearing name badges.
Facility failed to have a QA program in place to correct quality concerns and ensure quality issues did not reoccur.
Facility failed to ensure magnetically locked doors in a means of egress could be readily unlocked and opened in 4 of 7 smoke compartments.
Facility allowed hazard room doors to be held open by unapproved methods in 1 of 7 smoke compartments.
Facility failed to have the fire alarm and all components inspected semiannually.
Facility failed to meet all criteria for areas open to the exit corridor by not installing smoke detectors in dining rooms and great room.
Facility failed to complete dressing change in a manner to prevent potential cross contamination for one resident.
Facility failed to inspect and test all fire doors annually throughout the facility.
Report Facts
Resident census: 31
Facility capacity: 64
Call lights over 10 minutes: 22
Call lights over 10 minutes: 20
Call lights over 10 minutes: 8
Call lights over 10 minutes: 50
Call lights over 10 minutes: 11
Call lights over 10 minutes: 11
Call lights over 10 minutes: 1
Call lights over 10 minutes: 43
Call lights over 10 minutes: 56
Call lights over 10 minutes: 33
Call lights over 10 minutes: 61
Call lights over 10 minutes: 13
Call lights over 10 minutes: 53
Medication administration times: 7.3
Medication administration times: 8.55
Food temperature: 126.4
Food temperature: 155
Food temperature: 137
Food temperature: 140
Food temperature: 123
Food temperature: 150
Food temperature: 141
Food temperature: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent Hohensee | Administrator | Named in complaint investigation and interview |
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| LPN-F | Licensed Practical Nurse | Named in fall and abuse incident report |
| LPN-B | Licensed Practical Nurse | Named in dressing change and medication administration |
| LPN-K | Licensed Practical Nurse | Named in medication administration |
| MA-C | Medication Aide | Named in dressing change and fall supervision |
| NA-N | Nurse Aide | Named in dressing change |
| RN-G | Registered Nurse | Named in hospital transfer and care plan update |
| FSS | Food Service Supervisor | Named in food temperature and kitchen sanitation |
| MA-C | Medication Aide | Named in fall supervision |
| DON | Director of Nursing | Named in multiple interviews and findings |
| MS | Maintenance Supervisor | Named in fire safety and bed entrapment |
| ADM | Administrator | Named in multiple interviews and findings |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Mar 21, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to change interventions after residents have been identified at risk for falls.
Complaint Details
The complaint alleged the facility fails to change interventions after residents have been identified at risk for falls. The investigation substantiated this allegation with findings related to care plan revisions and identification of changes in condition leading to falls.
Findings
The facility failed to review and revise care plans after residents fell, specifically Resident 1's care plan was not updated after a fall which led to a fractured hip and subsequent death. Additionally, the facility failed to identify changes in condition for Resident 4 that led to a fall. Both deficiencies violated federal and state regulations.
Deficiencies (2)
Failure to review and revise Resident 1's care plan after a fall to prevent further falls and injury.
Failure to identify a change in condition for Resident 4 which led to a fall.
Report Facts
Census: 42
Sample size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Author of the complaint investigation letter |
| RN-A | Registered Nurse | Interviewed nurse who confirmed care plan deficiencies |
Inspection Report
Annual Inspection
Census: 47
Capacity: 64
Deficiencies: 19
Date: Dec 20, 2017
Visit Reason
Annual inspection of Blue Valley Lutheran Nursing Home to assess compliance with Medicare/Medicaid participation requirements, Life Safety Code, and other regulatory standards.
Findings
The facility was found not in compliance with several regulatory requirements including life safety code violations related to egress doors, sprinkler system maintenance, corridor safety, electrical safety, and resident rights. Deficiencies included failure to maintain clear access to electrical panels, improper use of bed rails, failure to complete registry checks for staff, failure to investigate and report injuries of unknown origin, and inadequate care planning for pressure ulcers and seizure disorder.
Deficiencies (19)
Failed to ensure delayed egress door was functional for required exit door in 2 of 6 smoke compartments.
Failed to prohibit storage of items in the East Exit Stairwell causing obstruction.
Failed to prevent obstruction of sprinkler heads and ensure all sprinkler components were in place in 1 of 6 smoke compartments.
Failed to separate Physical Therapy treatment area from exit corridor allowing smoke to spread.
Failed to provide required clear space in front of electrical panels and allowed storage to obstruct access.
Failed to monitor and prohibit use of portable space heaters in 1 of 6 smoke compartments.
Failed to provide a remote annunciator panel for emergency generator in an attended location.
Failed to conduct all required weekly and monthly inspections of the emergency generator.
Failed to post 'Oxygen in Use, No Smoking' signs on rooms where oxygen was administered.
Failed to complete APS/CPS registry checks for 3 of 6 nurse aides.
Failed to treat residents with respect and dignity; staff entered rooms without permission, fought in front of residents, ignored requests, failed to cover residents, and spoke derogatorily.
Failed to follow facility policy to screen prospective employees on nurse aide registry and failed to report and investigate suspicious injury of unknown origin for a resident.
Failed to report suspicious injury of unknown origin to state agency within required timeframe.
Failed to investigate suspicious injury of unknown origin for a resident.
Failed to care plan interventions for prevention of pressure sore development for a resident.
Failed to document interventions to address seizure disorder on a resident's care plan.
Failed to implement measures to prevent facility acquired pressure ulcer for a resident.
Failed to assess for necessity and obtain permission prior to use of bed rails for 2 residents.
Failed to monitor bed rails and mattresses for potential entrapment hazards for 2 residents.
Report Facts
Deficiencies cited: 17
Facility census: 47
Total licensed capacity: 64
Residents affected by egress door deficiency: 19
Residents affected by stairwell storage deficiency: 19
Residents affected by oxygen signage deficiency: 13
Residents sampled for dignity issues: 7
Residents sampled for care plan review: 20
Residents with pressure ulcers: 1
Residents with seizure disorder: 1
Residents with bed rails assessed: 2
Residents with bed rails monitored: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-E | Nurse Aide | Failed APS/CPS registry checks prior to employment. |
| NA-F | Nurse Aide | Failed APS/CPS registry checks prior to employment. |
| NA-G | Nurse Aide | Failed APS/CPS registry checks prior to employment. |
| NA-D | Nurse Aide | Failed nurse aide registry check prior to employment. |
| NA-E | Nurse Aide | Failed nurse aide registry check prior to employment. |
| Maintenance Staff A | Confirmed multiple facility deficiencies including delayed egress door failure, sprinkler head obstruction, electrical panel obstruction, and portable heater presence. | |
| Maintenance Supervisor | Removed signage and obstructions, monitored fire doors, and implemented corrective actions for sprinkler and electrical deficiencies. | |
| Administrator | Confirmed registry check deficiencies and lack of injury reporting; responsible for oversight and corrective action. | |
| LPN A | Licensed Practical Nurse | Confirmed pressure ulcer was facility acquired. |
| RN B | Registered Nurse | Confirmed pressure ulcer was facility acquired and care plan deficiencies. |
| NA H | Nurse Aide | Reported care plan used for resident care information. |
| RN I | Registered Nurse | Confirmed lack of seizure disorder interventions on care plan. |
| NA J | Nurse Aide | Reported residents able to move in bed without assistance. |
| DON | Director of Nursing | Confirmed lack of bed rail assessments and monitoring; responsible for monitoring care plan audits and staff education. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Nov 29, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Blue Valley Lutheran Nursing Home on November 29-30, 2017, regarding allegations of failure to notify the department of adverse events, insufficient staffing, delayed medical treatment, and failure to submit investigations within 5 working days.
Complaint Details
The complaint investigation addressed allegations that the facility failed to notify the department of adverse events, ensure sufficient staffing, provide prompt medical treatment, and submit investigations within 5 working days. The investigation found the failure to submit investigations was corrected prior to the visit, and no violations were found for the other allegations.
Findings
The facility failed to submit investigations within 5 working days for some residents, but this was corrected prior to the onsite investigation and no deficiency was imposed. No violations were found related to notification of adverse events, staffing sufficiency, or prompt medical treatment. A separate deficiency was cited for failure to secure hazardous chemicals, posing a risk to three residents who roam into open rooms.
Deficiencies (1)
Failed to ensure potential hazardous chemicals were stored in a secure area, potentially affecting three residents who roam into open rooms.
Report Facts
Facility census: 47
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Aug 7, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Blue Valley Lutheran Nursing Home on August 7-8, 2017, regarding allegations of failure to provide care for bladder elimination, housekeeping, skin breakdown prevention and healing, and adherence to practitioner's orders.
Complaint Details
The complaint investigation was substantiated with a violation found related to failure to prevent skin breakdown (Federal tag F314 and State Licensure Number 175 NAC 12-006.09D2a).
Findings
The facility was found compliant with bladder elimination, housekeeping, skin breakdown healing, and adherence to practitioner's orders. However, the facility was cited for failing to prevent skin breakdown due to lack of preventative pressure ulcer interventions for 2 of 4 residents sampled.
Deficiencies (1)
Facility failed to initiate preventative pressure ulcer interventions on 2 (Resident 100 and 112) out of 4 residents sampled.
Report Facts
Resident census: 46
Residents sampled: 4
Residents with deficient care: 2
Plan of correction completion date: Aug 24, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
| Kerrey Miller | Administrator | Facility administrator addressed in the report |
| DON | Director of Nursing | Confirmed lack of skin assessment and pressure ulcer interventions for Resident 100 |
| MDS Nurse | Confirmed no pressure ulcer interventions documented for Resident 100 | |
| DS | Dietary Supervisor | Unaware of Resident 112's pressure ulcers and risk |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Feb 8, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to provide appropriate positioning transfers, failure to follow the plan of care, and failure to protect residents from injury at Blue Valley Lutheran Nursing Home.
Complaint Details
The complaint alleged failure to provide appropriate positioning transfers, failure to follow the plan of care, and failure to protect residents from injury. The investigation substantiated the failure to follow the plan of care but found compliance with the other allegations.
Findings
The investigation found the facility compliant with appropriate positioning transfers and protecting residents from injury, but in violation of Federal tag F280 and State Licensure Number 175 NAC 12-0006.09C1c for failing to update the care plan to reflect a resident's declining functional status and increased assistance needs after hospitalization and injury.
Deficiencies (1)
Failure to update the care plan for Resident 214 to reflect current status and increased assistance needs after hospitalization and fractured arm.
Report Facts
Facility census: 47
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed letter regarding complaint investigation findings |
| Pam Kozeal | Administrator | Facility administrator addressed in the letter |
| Staff A | Interviewed staff providing information about Resident 214's condition and care | |
| Director of Nursing | DON | Confirmed care plan deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jan 4, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Blue Valley Lutheran Nursing Home on January 4, 2017. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The complaint investigation addressed multiple allegations including failure to submit investigations timely, failure to treat residents with respect and dignity, insufficient supervision, failure to provide medications as ordered, failure to use fall interventions, failure to secure narcotic medications, and failure to investigate causative factors in falls. Most allegations were unsubstantiated except for concerns about narcotic medication security.
Findings
The investigation found no violations related to timely submission of investigations, respect and dignity of residents, supervision of residents, medication administration, fall interventions, and investigation of causative factors in falls. However, the facility did fail to follow appropriate procedures for security of narcotic medications, though this did not rise to the level of deficient practice.
Deficiencies (1)
Failure to follow appropriate procedures for security of narcotic medications.
Report Facts
Facility census: 49
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit | Signed the inspection report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to ensure residents are free from abuse.
Complaint Details
The allegation that the facility failed to ensure residents were free from abuse was investigated and found to be unsubstantiated.
Findings
The investigation found no evidence of abuse; observations, interviews, and record reviews confirmed residents were not abused and the facility was in compliance with regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the report and is the contact person for the investigation |
Inspection Report
Annual Inspection
Census: 50
Capacity: 64
Deficiencies: 10
Date: Sep 7, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Blue Valley Lutheran Nursing Home from September 7, 2016 to September 13, 2016.
Complaint Details
The complaint investigation found no violations related to allegations of failure to identify changes in condition, follow practitioner's orders, or notify appropriate parties. The facility was found to be in compliance.
Findings
The complaint allegations regarding failure to identify changes in condition, follow practitioner's orders, and notify appropriate parties were found to be in compliance. The annual survey identified deficiencies related to accident hazards, life safety code violations including door latching, emergency lighting, fire alarm and sprinkler system policies, oxygen storage, and electrical safety.
Deficiencies (10)
Failed to ensure foot rests were used during wheelchair transports for 5 residents and failed to control resident room hot water temperatures for 8 rooms.
Failed to ensure corridor doors were capable of latching, allowing smoke and fire to migrate into exit corridors affecting 9 residents.
Failed to maintain doors to hazardous areas to provide smoke resistant partitions, allowing fire and smoke to migrate into corridors affecting 50 residents.
Allowed use of more than one locking/latching device on doors within means of egress, prohibiting or delaying egress affecting 17 residents.
Failed to provide uninterruptable emergency lighting in Great Room, Sun Room, Dining/Activity Room and Community Room affecting all residents.
Failed to provide exit sign for second required exit in Great Room, potentially delaying evacuation for all residents.
Failed to maintain sprinkler heads in operating condition during room renovations, delaying sprinkler operation affecting 5 residents.
Failed to separate oxygen cylinders from combustibles and secure oxygen cylinders in storage, increasing fire risk and potential for emergency errors affecting all residents.
Did not prohibit use of extension cords beyond temporary installation, increasing risk of electrical fire affecting 15 residents.
Failed to have complete fire watch policy for sprinkler and fire alarm system outages over 4 hours, risking inadequate emergency response affecting all residents.
Report Facts
Deficiencies cited: 10
Facility census: 50
Total licensed capacity: 64
Residents affected by door latching deficiency: 9
Residents affected by hazardous area door deficiencies: 50
Residents affected by locking device deficiency: 17
Residents affected by emergency lighting deficiency: 50
Residents affected by sprinkler head deficiency: 5
Residents affected by oxygen storage deficiency: 50
Residents affected by extension cord deficiency: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 14, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use appropriate interventions to prevent injuries and accidents.
Complaint Details
The complaint alleged that the facility fails to use appropriate interventions to prevent injuries and accidents. The complaint was investigated and found to be unsubstantiated as no violations were identified.
Findings
The investigation found that the facility does put interventions in place to prevent injury and accidents, and no violations or concerns were identified during the onsite unannounced investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and is the contact person for questions regarding the investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 5, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint at Blue Valley Lutheran Nursing Home from May 5, 2016 to May 10, 2016 by the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations that the facility failed to submit investigations in 5 working days, failed to protect residents from abuse and/or neglect, and failed to have interventions in place for residents at risk for falls. The failure to submit investigations was substantiated in one instance but not found to be a pattern. The other allegations were not substantiated.
Findings
The facility failed to submit investigations within 5 working days in one instance but this was not found to be a pattern and no citations were issued. The facility was found to protect residents from abuse and neglect and to have appropriate interventions in place for residents identified at risk for falls, with no violations related to these issues.
Deficiencies (1)
Failure to submit investigations within 5 working days in one instance
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report and contact person for questions |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 11
Date: Aug 31, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Blue Valley Lutheran Nursing Home from August 31, 2015 to September 9, 2015.
Complaint Details
The complaint alleged the facility failed to ensure residents are treated with respect and dignity. The investigation confirmed a violation related to posting private medical information in visible areas, but no violation was found regarding fall interventions.
Findings
The facility failed to ensure residents were treated with respect and dignity due to posting private medical information in areas visible to others. The facility also failed to provide a safe, clean, and homelike environment as medical equipment was stored in dining rooms, and maintenance issues were noted throughout the facility. Additionally, medication carts were found unlocked and accessible, and several life safety code violations were identified including lack of smoke detection for door release, failure to separate hazardous areas, inadequate exit lighting, incomplete fire drills, and deficiencies in fire alarm and sprinkler system maintenance.
Deficiencies (11)
Posting of private medical information in areas visible to others for two residents.
Medical equipment stored in dining rooms affecting homelike environment.
Facility failed to maintain sanitary, orderly, and comfortable interior with multiple maintenance issues in resident rooms and common areas.
Medication carts unlocked and accessible to unauthorized persons.
Failed to provide smoke detection for door release service in 1 of 6 smoke compartments.
Failed to separate hazardous areas from exit corridor in 2 of 6 smoke compartments.
Failed to provide more than one lightbulb outside each designated exit from 2 of 6 smoke compartments.
Failed to conduct fire drills for 1 of 3 shifts in accordance with NFPA 101.
Fire alarm system not maintained and inspected every six months as required.
Automatic sprinkler system not maintained in reliable operating condition and inspections exceeded required intervals.
Failed to use electrical wiring and equipment in accordance with NFPA 70; unsafe power strips and blocked electrical panel access.
Report Facts
Facility census: 50
Deficiency count: 11
Fire drill missing shift: 1
Fire alarm inspection interval: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Wehrs | Registered Nurse | Investigator conducting complaint and annual survey |
| Victoria Smith | Registered Nurse | Investigator conducting complaint and annual survey |
| Rebecca Young | Registered Nurse | Investigator conducting complaint and annual survey |
| Eve Lewis | Program Manager | Signed letter regarding plan of correction instructions |
| Kathy Retzlaff | Administrator | Facility administrator named in report |
| LPN A | Licensed Practical Nurse | Confirmed medication carts must be locked if unattended |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 8
Date: Jun 25, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Blue Valley Lutheran Nursing Home on June 25, 2014-July 1, 2014, including review of resident records, observation of care and services, and interviews with residents, family members and staff.
Complaint Details
The complaint investigation included allegations that the facility failed to notify family of change in condition, failed to ensure staff washed hands prior to resident care, failed to ensure adequate housekeeping, failed to meet nutritional needs, failed to respond promptly to call lights, failed to administer medications according to the Five Rights, and failed to maintain equipment to prevent accidents. The facility was found in violation only for failure to notify family of Resident 64's significant change in condition.
Findings
The facility was found in violation for failing to notify Resident 64's family/legal representative of a significant change in condition. Other complaint allegations such as hand washing, housekeeping, meal service, call light response, medication administration, and equipment maintenance were found to be in compliance.
Deficiencies (8)
Facility failed to provide a written list of covered and non-covered Medicare and Medicaid items and services for Resident 12 on admission.
Facility failed to notify Resident 64's responsible party of a significant change in condition related to a lost packing in a wound.
Facility failed to maintain 2 of 7 exit doors in accordance with NFPA 101 Life Safety Code, including excessive force needed to open West Wing South Exit Door and missing delayed egress signage on East Stairwell Exit Door.
Facility failed to conduct quarterly fire drills on each shift for 1 of 3 shifts.
Facility failed to have fire alarm system inspected semi-annually within required 6 month intervals.
Facility failed to have range hood suppression system inspected semi-annually within required 6 month intervals.
Facility failed to eliminate the possibility of creating an oxygen-enriched atmosphere due to unattended running oxygen concentrators in Resident Rooms 209 and 233.
Facility failed to use electrical wiring and equipment in accordance with NFPA 70, including use of non-medical grade power strips and daisy-chained power strips in resident rooms and medical records room.
Report Facts
Facility census: 41
Medication occurrences: 25
Exit doors: 7
Residents affected by exit door issue: 22
Fire drill missing: 1
Fire alarm inspection interval: 8
Range hood suppression inspection interval: 6
Oxygen concentrators unattended: 2
Power strips observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Retzlaff | Interim Administrator | Named in initial comments and interview confirming findings |
| Eve Lewis | Program Manager, Office of Long Term Care Facilities | Signed complaint investigation letter |
| Jean Obermier | Registered Nurse | Surveyor involved in complaint and annual survey |
| Frances Prokop | Registered Nurse | Surveyor involved in complaint and annual survey |
| Susan Griepenstroh | Registered Nurse | Surveyor involved in complaint and annual survey |
| Nancy Hauschild | Nutrition/dietitian | Surveyor involved in complaint and annual survey |
| Administrator A | Confirmed findings during life safety code inspection and interviews | |
| Social Service Director | Acknowledged admission packet deficiencies and notification issues | |
| Director of Nursing | Acknowledged failure to notify family of Resident 64's condition change |
Inspection Report
Routine
Census: 53
Deficiencies: 11
Date: May 9, 2013
Visit Reason
Routine inspection of Blue Valley Lutheran Nursing Home to assess compliance with regulatory requirements including care services, life safety code, medication management, and facility safety.
Findings
The facility failed to ensure proper assessment and care for residents with bowel elimination issues, failed to provide safe transfer and wheelchair positioning for a resident with a leg fracture, had medication monitoring and administration deficiencies, and multiple life safety code violations including door latching, smoke barrier integrity, exit door operation, fire drill scheduling, sprinkler system maintenance, and exit lighting.
Deficiencies (11)
Facility failed to ensure two residents were assessed per facility policy for bowel elimination, with inadequate documentation and care planning for bowel incontinence and constipation.
Facility failed to provide safe transfer and wheelchair seating for Resident 36 with fractured leg and cast, and failed to monitor skin condition and swelling.
Facility failed to provide monitoring for use of Pravastatin for Resident 26 to assure safety and effectiveness.
Facility failed to administer medications properly, leaving medications unattended and not ensuring timely administration.
Corridor doors lacked positive latching and were impeded from closing, failing to resist passage of smoke.
Smoke barrier doors failed to maintain smoke resistance and automatic closing, with paint buildup and missing self-closing devices.
Hazardous areas were not separated by partitions and self-closing doors to ensure smoke resistance to exit corridor.
Exit door required excessive force to open, exceeding regulatory limits.
Exit discharge lighting had only one bulb, risking darkness if bulb failed.
Fire drills were not held under varied conditions at different times of day and month, limiting staff preparedness.
Sprinkler system piping was obstructed by data wires, risking sprinkler inoperability.
Report Facts
Facility census: 53
Residents affected by corridor door latching: 24
Residents affected by smoke barrier door deficiencies: 14
Residents affected by hazardous area door deficiencies: 14
Residents affected by exit door force deficiency: 14
Residents affected by sprinkler obstruction: 7
Fire drills reviewed: 15
Evening shift fire drills: 5
Day shift fire drills: 5
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 6
Date: Mar 22, 2012
Visit Reason
The inspection was conducted as a regulatory survey to assess compliance with licensure regulations and life safety codes for Blue Valley Lutheran Nursing Home.
Findings
The facility was found deficient in housekeeping and maintenance services, life safety code compliance including fire door latching, smoke separation, sprinkler system installation and supervision, and electrical safety standards.
Deficiencies (6)
Failed to provide maintenance, repair and housekeeping related to jagged and scuffed walls in resident rooms, baseboard gaps, and unclean lighting fixtures.
Doors protecting corridor openings failed to have latching hardware, compromising smoke separation.
Dietary Storage Room door failed to latch, compromising smoke resistive partition.
Sprinkler head improperly installed under an obstruction over four feet wide, risking inadequate fire suppression.
Automatic sprinkler system valves were not supervised by fire alarm system in multiple locations.
Electrical wiring and equipment not in accordance with NFPA 70, including improper use of power strips and open junction box.
Report Facts
Facility census: 55
Facility census: 56
Facility census: 56
Total licensed beds: 64
Inspection Report
Follow-Up
Census: 58
Capacity: 64
Deficiencies: 11
Date: Mar 3, 2011
Visit Reason
This follow-up inspection was conducted to verify correction of previously identified deficiencies related to housekeeping, maintenance, comprehensive care plans, infection control, medication management, and life safety code compliance at Blue Valley Lutheran Nursing Home.
Findings
The facility demonstrated correction of multiple deficiencies including housekeeping and maintenance issues, comprehensive care plan development and monitoring, infection control practices, medication storage and reconciliation, and life safety code violations related to door latching and electrical outlets. Plans of correction were implemented and monitored with completion dates ranging from March 1 to April 8, 2011.
Deficiencies (11)
Facility failed to ensure one resident room had no large tears and holes in bathroom flooring.
Six resident rooms had old hopper pedals under bathroom sinks that were sticking out causing a hazardous environment.
Some resident rooms had deep scratches and marring on closet doors and furniture pieces.
Facility failed to develop comprehensive care plans with measurable objectives for residents.
Facility failed to ensure dental condition/history was documented and monitored in care plans.
Facility failed to review and revise comprehensive care plans to reflect changes in care and treatment.
Facility failed to maintain positive latching of corridor doors, allowing smoke and fire to migrate.
Facility failed to properly clean blood glucose monitors between residents, risking infection.
Facility failed to maintain accurate reconciliation and accounting for controlled medications for one resident.
Facility failed to prevent pressure ulcers and provide adequate skin care for residents.
Facility failed to serve meals at appropriate temperatures in assisted dining rooms.
Report Facts
Facility census: 58
Sampled residents: 30
Number of doors with latching issues: 10
Number of resident rooms with old hopper pedals: 6
Number of residents with pressure ulcers: 1
Number of residents affected by meal temperature issue: 8
Number of residents affected by infection control issue: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lyle Hight | CEO | Signed Plan of Correction letter dated 3/24/2011 |
| Janelle Bruning | Mentioned in psychoactive medication review | |
| Kathleen Philippi | Mentioned in psychoactive medication review | |
| Rachel Jiskra | Mentioned in psychoactive medication review | |
| Michelle Goedeken | Mentioned in psychoactive medication review | |
| Sheryl Achterberg | Mentioned in psychoactive medication review | |
| Rosemary Chatel | Mentioned in psychoactive medication review | |
| Jody Huber | Mentioned in psychoactive medication review | |
| Tammey Vonniessen | Mentioned in psychoactive medication review | |
| Heather Whitehead | LPN-C | Mentioned in psychoactive medication review |
| L. Gibson | RN | Mentioned in cleaning blood glucose meters checklist |
| S. Luehring | RN | Mentioned in cleaning blood glucose meters checklist |
| J. Bowman | LPN | Mentioned in cleaning blood glucose meters checklist |
| E. Campbell | LPN | Mentioned in cleaning blood glucose meters checklist |
| M. Ginther | LPN | Mentioned in cleaning blood glucose meters checklist |
| L. Ralston | LPN-C | Mentioned in cleaning blood glucose meters checklist |
| J. Bruning | RN DON | Mentioned in cleaning blood glucose meters checklist and medication review |
| K. Philippi | RN | Mentioned in cleaning blood glucose meters checklist |
| D. Werner | Mentioned in cleaning blood glucose meters checklist | |
| J. Blair | MA | Mentioned in cleaning blood glucose meters checklist |
| S. Achterberg | LPN | Mentioned in cleaning blood glucose meters checklist |
| T. Vonniessen | LPN | Mentioned in cleaning blood glucose meters checklist |
| H. Whitehead | LPN-C | Mentioned in cleaning blood glucose meters checklist |
| S. Jiskra | LPN-C | Mentioned in cleaning blood glucose meters checklist |
| M. Goedeken | RN | Mentioned in cleaning blood glucose meters checklist |
| R. Chatel | LPN | Mentioned in cleaning blood glucose meters checklist |
| J. Huber | LPN | Mentioned in cleaning blood glucose meters checklist |
Notice
Capacity: 64
Deficiencies: 0
Date: APP2016
Visit Reason
This document serves to verify the licensure renewal of Blue Valley Lutheran Nursing Home and includes occupancy permit and ownership information.
Findings
The documents confirm the facility's licensure renewal through 03/31/2017, certify the maximum occupancy at 64 beds, and provide ownership and administrative details.
Report Facts
Licensed capacity: 64
Renewal expiration date: Mar 31, 2017
Renewal fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Retzlaff | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Kerrey Miller | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Richard Mosier | President | Signed as authorized representative on the renewal application and listed on the Corporate Board of Directors. |
| Doug Bruning | Vice President | Signed as authorized representative on the renewal application and listed on the Corporate Board of Directors. |
Notice
Capacity: 64
Deficiencies: 0
Date: APP2017
Visit Reason
This document serves as verification of the renewal of the SNF/NF dual certification license for Blue Valley Lutheran Nursing Home and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility meets statutory requirements for skilled nursing and nursing facility certification, with a licensed capacity of 64 beds. The occupancy permit confirms compliance with fire safety codes as of the inspection date.
Report Facts
Licensed capacity: 64
License expiration date: 2018
Occupancy permit date: Sep 8, 2016
Notice
Capacity: 64
Deficiencies: 0
Date: APP2018
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Blue Valley Lutheran Nursing Home and includes the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The facility is licensed through 3/31/2019 with a total licensed capacity of 64 beds. The occupancy permit confirms the maximum occupancy as 64 beds, issued on 12/20/2017.
Report Facts
Licensed beds: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent Hohensee | CEO and NH Administrator | Named as Administrator and CEO in renewal application and staff list |
| Tiffany Nutsch | Director of Nursing | Named as Director of Nursing in renewal application |
| Doug Bruning | President | Named as President of Corporate Board of Directors |
| Gary Hinrichs | Named as member of Corporate Board of Directors | |
| Ardith Hoins | Named as member of Corporate Board of Directors | |
| Carol Krueger | Named as member of Corporate Board of Directors | |
| Pastor Connie Raess | Named as member of Corporate Board of Directors | |
| Shirley Rippe | Named as member of Corporate Board of Directors | |
| Delvin Stahl | Named as member of Corporate Board of Directors | |
| Jim Steider | Named as member of Corporate Board of Directors | |
| David McCray | CH Administrator | Named in staff list |
| Lori Wittler | CFO | Named in staff list |
| Megan Hinrichs | Marketing and Development | Named in staff list |
| Rosalie Lange | Named in staff list |
Document
Capacity: 64
Deficiencies: 0
Date: APP2019
Visit Reason
The documents serve to verify the renewal of the SNF/NF dual certification license for Blue Valley Lutheran Nursing Home and provide the occupancy permit and related facility information.
Findings
The documents confirm the facility's licensure renewal status, ownership details, staff contacts, and fire marshal occupancy permit with a maximum capacity of 64 beds.
Report Facts
Total licensed beds: 64
Renewal expiration date: Mar 31, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent Hohensee | CEO and NH Administrator | Named as facility administrator in renewal application and staff list. |
| Doug Chos | CH Administrator | Named in staff list. |
| Lori Wittler | CFO | Named in staff list. |
| Megan Hinrichs | Marketing and Development | Named in staff list. |
| Ardith Hoins | Secretary | Named in ownership and staff information. |
| Jim Steider | President | Named in corporate board of directors. |
| Delvin Stahl | Vice President | Named in corporate board of directors. |
| Pastor Connie Raess | Named in corporate board of directors. | |
| Rosalie Lange | Named in corporate board of directors. | |
| Gary Hinrichs | Named in corporate board of directors. | |
| Joetta Brandt | Named in corporate board of directors. | |
| Carol Krueger | Named in corporate board of directors. | |
| Janelle Bruning | Named in corporate board of directors. |
Document
Capacity: 64
Deficiencies: 0
Date: APP2020
Visit Reason
The documents serve to verify the licensure renewal of Blue Valley Lutheran Nursing Home, confirm the facility's licensed bed capacity, and provide the occupancy permit issued by the Nebraska State Fire Marshal.
Findings
The documents confirm that Blue Valley Lutheran Nursing Home is licensed as a Skilled Nursing Facility with a total licensed capacity of 64 beds. The occupancy permit was issued on 2019-03-14. No inspection findings or deficiencies are reported in these documents.
Report Facts
Licensed beds: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Chos | Administrator and CEO and NH Administrator | Named as Administrator on the renewal application and CEO/NH Administrator in the corporate board listing. |
| Amanda Beam | Director of Nursing | Named as Director of Nursing on the renewal application and in the facility floor plan. |
| Ardith Hoins | Secretary | Named as Secretary on the renewal application and corporate board listing. |
| Carol Krueger | President | Named as President on the renewal application and corporate board listing. |
| Mark Manchester | Deputy State Fire Marshal | Named as the inspector who approved the occupancy permit. |
Notice
Capacity: 64
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves to verify that Blue Valley Lutheran Nursing Home's SNF/NF dual certification license is renewed and valid through the date indicated on the renewal card, and includes the renewal application for the nursing home license.
Findings
The document confirms the facility meets statutory requirements for licensure renewal and provides updated ownership and certification information. It does not report inspection findings or deficiencies.
Report Facts
Total licensed capacity: 64
Renewal license expiration date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Chos | Administrator, CEO | Named in the renewal application and as CEO in contact information |
| Becky Petras | Director of Nursing, RN DON | Named in the renewal application and contact information |
Notice
Capacity: 64
Deficiencies: 0
Date: APP2022
Visit Reason
This document serves to verify the licensure renewal of Blue Valley Lutheran Nursing Home and includes the Nursing Home Licensure Renewal Application.
Findings
The document certifies that Blue Valley Lutheran Nursing Home meets statutory requirements for SNF/NF dual certification and provides renewal information. It includes ownership, facility capacity, and services offered.
Report Facts
Total licensed beds: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Chos | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Jamie Houser | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Gary J. Amihone | Chief Medical Officer, Director, Division of Public Health | Signed the licensure verification. |
Document
Capacity: 64
Deficiencies: 0
Date: APP2023
Visit Reason
The documents pertain to the renewal of the nursing home license for Blue Valley Lutheran Nursing Home and related administrative and safety information.
Findings
No inspection findings or deficiencies are reported. The documents verify licensure renewal, occupancy permit, and provide administrative and emergency evacuation information.
Report Facts
Total licensed beds: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Chos | Administrator | Named as Administrator on the Nursing Home Licensure Renewal Application. |
| Jamie Houser | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
Notice
Capacity: 64
Deficiencies: 0
Date: APP2024
Visit Reason
This document serves as a renewal application for the nursing home license of Blue Valley Lutheran Nursing Home and includes related licensing and occupancy permits.
Findings
The documents certify that Blue Valley Lutheran Nursing Home meets statutory requirements for licensure renewal and includes confirmation of licensed bed capacity and occupancy permit.
Report Facts
Total licensed beds: 64
Renewal license fee: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Wittler | Interim Administrator | Named in the Nursing Home Licensure Renewal Application |
| Keith Trimm | RN DON (Director of Nursing) | Named in the Nursing Home Licensure Renewal Application |
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