Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Blue Valley Lutheran Nursing Home
Hebron, NE · 64 certified beds · Last Life Safety survey July 10, 2025
CMS Certification Number 285259 · first certified July 2004
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NE
27 citations — more than 86% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 19 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (July 2026 to September 2026). Most NE facilities have been surveyed by October 2026. This facility’s last Life Safety survey was July 2025. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 27 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 27 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 27 |
| Median facility in NE | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 25, 2023 | 3 |
| June 27, 2024 | 5 |
| July 10, 2025 | 19 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-07-10 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-07-10 |
| K-0500 | Meet other general requirements that are deficient. | 1 | 2025-07-10 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2025-07-10 |
| K-0222 | 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. | 1 | 2025-07-10 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2025-07-10 |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | 1 | 2025-07-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-07-10 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 4
- Egress Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 10, 2025 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0900 | Meet Health Care Facilities Code mechanical requirements. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 26, 2025) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (August 26, 2025) |
June 27, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 31, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 31, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 31, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 31, 2024) |
May 25, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 12, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.