BLUE VALLEY LUTHERAN CARE HOME

Nursing Home Inspector

P O BOX 166, 755 SOUTH 3RD STREET
HEBRON, NE 68370
Thayer County
Phone: 402-768-3930
Provider Number: 28E279
Last Inspection: 07/18/2016

About the Nursing Home

Number of Beds: 64
Number of Residents: 38
Beds Available: 26
Percent Occupancy: 59%
Insurance Accepted: Medicaid
Types of Councils: Resident
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

11

Facility
8

County
20

NE
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

11

2016
16

2015
24

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/18/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Actual 4 9/26/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 9/26/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 9/26/2016
 

5/21/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 7/7/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/7/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 7/7/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 7/7/2015
 

4/30/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 6/9/2014
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/9/2014
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 6/9/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/9/2014
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 6/9/2014
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Minimal 4 6/9/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 6/9/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/16/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 9/12/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NE State Avg
Number of Residents 38 40.33 53.60
Registered Nurses 0.60 0.68 0.76
Licensed Practical / Vocational Nurses 0.90 0.86 0.68
Certified Nursing Assistants 2.93 2.56 2.49
Total Staff Hours 4.44 4.10 3.93

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NE State Avg%
of high risk long-stay residents with pressure ulcers 0 1 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 95 98 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 98 96
of long-stay residents experiencing one or more falls with major injury 3 4 4
of long-stay residents who have depressive symptoms 1 7 5
of long-stay residents who lose too much weight 9 5 7
of long-stay residents who received an antianxiety or hypnotic medication 38 25 21
of long-stay residents who received an antipsychotic medication 46 25 18
of long-stay residents who self-report moderate to severe pain 0 7 9
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 9 18 19
of long-stay residents whose need for help with daily activities has increased 9 17 15
of long-stay residents with a catheter inserted and left in their bladder 0 2 2
of long-stay residents with a urinary tract infection 2 3 5
of low risk long-stay residents who lose control of their bowels or bladder 48 54 46