Wakefield Health Care Center
306 Ash Street, Wakefield, NE 68784 · Government - City · 40 certified beds · (402) 287-2244 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0606) — most recent Jun 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.0% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.8% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.9% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.7% | 4.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.3% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.8% | 19.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 34.8% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.7% | 20.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 75.9% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.66 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.45 | 1.92 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 5.9–14.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.55 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 29.7 residents a day — about 74% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.70 hrs/resident/day on weekends vs 5.19 on weekdays — 9% thinner on weekends. RN hours go from 0.65 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · E2025-07-22 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview; the facility failed to ensure Residents 5, 6 and 13's drug regimens were free from unnecessary medications as the facility failed to attempt Gradual Dose Reductions (GDR)s for Residents 13 and 6's antipsychotic (drugs that affect the mind, emotions, and behavior) medications and to ensure Resident 5's as needed antipsychotic medication was limited to 14 days. The sample size was 5 and the facility census was 31. Findings are: A. Review of the facility policy “Antipsychotic Medication Use” with a revision date of 7/2025 revealed the following: -the facility was to evaluate behavior interventions before using psychotropic medications and to eliminate unnecessary medications. The residents would be free from chemical restraints imposed for purposes of discipline or convenience or not required to treat the residents' medical symptoms. -resident were not to be given antipsychotic drugs unless the medication was necessary. -residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY S483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.This requirement is not met as evidenced by:LICENSURE REFERENCE NUMBER 175 NAC 12-006.12(D)(i):Based on observation, record review and interview; the facility failed to provide safe storage of drugs as: 1) Medications were left on top of the medication cart and unattended, 2) The medication cart was left unlocked with no staff in attendance, 3) The keys were in the narcotic lock box with no nurse within visualization and 4) Medications were administered to resident's without staff supervision. The total sample size was 19 and the facility census was 31.Findings are:Findings are:A. Review of the facility policy titled Storage of Medications with a revised date of 5/25 included the following:-The facility would store all drugs in a safe, secure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 12-006.09Based on record reviews and interviews; the facility failed to complete neurological assessments to assess for potential injury after unwitnessed falls for Residents 2 and 5. The sample size was 2 and the facility census was 31. Findings are: A. Review of the facility policy Neurological Assessment last revised October 2010 revealed guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) following a fall with a suspected head injury or trauma; or 4) when indicated by resident condition. Staff were to always include frequent vital signs and any change in vital signs or neurological status would be reported to the physician immediately. Staff were to perform neurological checks per facility protocol: Every 15 minutes x5; every 30 minutes x4; every hour x5, then every shift (AM shift was 6 AM-6 PM and PM shift was 6 PM-6 AM) for 72 hours. For residents that received anticoagulant (blood thinners), neurological checks would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to ensure Residents 6 and 13's drug regimens were free from unnecessary medications as the facility failed to attempt Gradual Dose Reductions (GDR)s for the residents psychoactive (drugs which affect mental processes such as perception, consciousness, cognition, mood and emotions) medications. The sample size was 5 and the facility census was 31. Findings are: A. Review of the facility policy “Antipsychotic Medication Use” with a revision date of 7/2025 revealed the following: -the facility was to evaluate behavior interventions before using psychotropic medications and to eliminate unnecessary medications. The residents would be free from chemical restraints imposed for purposes of discipline or convenience or not required to treat the residents' medical symptoms. -resident were not to be given antipsychotic drugs unless the medication was necessary. -residents who used psychotropic medications received GRD’s…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-27 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY D. Review of Resident 12's MDS dated [DATE] revealed the following: -diagnoses of dementia, diabetes, arthritis, anxiety, and depression, -severe cognitive impairment, -behaviors towards other people and not towards other people, -the resident was dependent with toileting, dressing, personal hygiene, bed mobility, and transfers, and -the resident received antipsychotic, antianxiety, and antidepressant medications. Review of Resident 12's Care Plan last revised 6/24/24 revealed the following: -staff were to administer psychotropic medications as ordered by the Physician and monitor side effects and effectiveness, -consult with pharmacy and the Physician to consider dose reductions when clinically appropriate, -discuss the need for ongoing need for use of medications with the physician. Review of Resident 12's Medication Administration Record revealed the resident had an order for Haloperidol (antipsychotic medication) give 0.25 milligrams (mg) by mouth every 4 hours as needed for delirium started 4/23/24 with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 (B) Licensure Reference Number 175 NAC 12-006.18(D) Based on observations, record review and interview; the facility failed to implement enhanced barrier precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO's) when providing assistance with high-contact care activities for Resident 4, to wash hands and change gloves at indicated intervals during the provision of cares for Resident 12, to transport soiled linens and to clean re-useable care equipment to prevent the potential for cross contamination. The total sample was size 17 and the facility census was 33. Findings are: A. Review of the facility policy Enhanced Barrier Precautions that employs gown and glove use during high contact resident care activities) with a review date of 5/2/24 revealed it was the policy of the facility to implement EBP's for the prevention of transmission of MDRO's. The following was identified regarding the initiation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interviews; the facility failed to provide 2 (Resident 5 and 18) of 3 sampled residents/representatives with the cost of continuing to receive skilled Medicare Services, a choice of whether to appeal the facilities Medicare determination to discontinue services, or the reason for the discharge from skilled Medicare services. The facility census was 33. Findings are: A. Review of the facility policy Advanced Beneficiary Notice with a revised date of 6/10/23 revealed the purpose of the policy was to ensure compliance with the Centers for Medicare & Medicaid Services (CMS) regulations by issuing an Advanced Beneficiary Notice (ABN) to residents and/or representatives who are no longer covered by Medicare Part A. Residents/representatives would also be informed of potential financial responsibilities for services that Medicare may not cover. In addition, the following was revealed: -The ABN must be provided to the resident or their legal representative at least 48 hours in advance of any services that are likely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to protect residents 2 and 5 from potential abuse related to an allegation of staff to resident abuse. This had the potential to affect all facility residents. The facility census was 33. Findings are: A. Review of the facility policy Abuse, Neglect, Misappropriation last reviewed 1/2024 revealed the following: -the facility would consider factors that indicated possible abuse such as staff, resident, or a family reporting abuse, verbal abuse of a resident was overheard, or failure to provide needs such as feeding, bathing, dressing, turning and positioning, -when suspicion of abuse, neglect or exploitation occurred, an investigation would be warranted, -the Administrator would investigate the incident and would include interviewing the resident's roommate if the resident, involved staff, and injuries found during a resident assessment, -while the investigation is conducted, accused individuals not employed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview; the facility failed to complete and submit an investigation of a fall with injury for Resident 25 and to submit an investigation of an elopement for Resident 1 within the required time frames. The sample size was 5 and the facility census was 33. Findings are: A. Review of the facility policy Abuse, Neglect, Misappropriation, last reviewed 1/2024 revealed the following: -the facility would consider factors indicating possible abuse such as staff, resident, or a family reporting abuse, if verbal abuse was overheard, or failure to provide needs such as feeding, bathing, dressing, turning, and repositioning, -once the resident is cared for and initial reporting has occurred, an investigation would be conducted, -the Administrator would investigate the incident and would include interviews from the resident's roommate, involved staff, and any injuries found during a resident assessment, -while the investigation is conducted, accused individuals not employed by the facility would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to ensure residents were free from unnecessary medications related to long term use of an antibiotic for 1 (Resident 18) of 5 sampled residents as there was no specified duration or supporting documentation for clinical use based on laboratory results. The facility census was 33. Findings are: A. Review of the facility policy Antibiotic Stewardship with a reviewed date of 6/2024 revealed the purpose of the program was to monitor the use of antibiotics for the facility residents. The goal of the Antibiotic Stewardship Program (ASP) was to promote the appropriate use of antibiotics, to maximize treatment outcomes and minimize unintended consequences of antibiotic therapy. If an antibiotic was indicated Prescribers were to provide complete orders including the following: -drug name, -dose, -frequency of administration, -duration of treatment (start and stop dates or number of days of therapy), -route of administration, and -indications of use. B. Review of Resident 18's Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2024-06-27 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.10D Based on observations, record review and interviews; the facility failed to ensure a medication error rate of less than 5%. Observations of 28 medications administered revealed 2 errors resulting in a medication error rate of 7.14%. The errors affected 2 (Residents 4 and 23) of 4 sampled residents. The facility census was 33. Findings are: A. Review of the facility policy Administering Medications with a review date of 4/2024 revealed the following: -Medications must be administered in accordance with the orders, including any required time frames. -Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). -The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, and right route before giving the medication. B. Review of Resident 4's Medication Administration Record (MAR) dated 6/1/24 to 6/30/24 revealed a physician's order for omeprazole (medication used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.12(D)(vi) Based on observations, record review and interview the facility failed to ensure an insulin medication was labeled correctly for 1 (Resident 23) of 4 sampled residents. The facility census was 33. Findings are: A. Review of the facility policy Storage of Medications with a review date of 4/2024 revealed drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. B. Review of the facility policy Administering Medications with a review date of 4/2024 revealed the individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. C. Review on 6/24/24 of Resident 23' Medication Administration Record (MAR) dated 6/1/24 to 6/30/24 revealed a physician's order with a start date of 4/18/24 (over 2 months ago) for Novolog Injection FlexPen (Insulin used to maintain a person's blood sugar levels within normal range) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interviews; the facility staff failed to thoroughly investigate resident to resident altercations and to assure interventions were put into place to prevent further altercations for 2 (Residents 5 and 81) of 2 sampled residents. The facility staff identified a census of 30. Findings are: A. Record review of a facility policy and procedure titled Abuse, Neglect, Misappropriation and Exploitation with a reviewed date of 6/23 revealed all residents had the right to be free from abuse. When there was suspicion of abuse, an investigation was to be conducted to try to determine root cause of the incident. The investigation was to include: -observation of residents who were non-verbal or cognitively impaired; -evaluation of the resident's behavior, affect and response to interaction and leading up to the incident; -a description of the environment at the time of the incident; and -involved staff and witnessed statements of the event. In cases of resident-to-resident abuse the following steps were to be taken:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure Resident 19's Pre-admission Screening and Resident Review (PASARR-federally mandated evaluation used to identify Mental Disorders (MD), Intellectual Disability (ID), or Related Disorders (RD) and to ensure appropriate facility placement with appropriate services), accurately reflected a potential MD. The sample size was 1 and the facility census was 30. Findings are: Record review of Resident 19's PASARR dated 2/13/23 revealed the resident had no MD including anxiety or psychotic disorders. Record review of Resident 19's Minimum Data Set (MDS-federally mandated comprehensive assessment used for the development of resident Care Plans) dated 4/14/23 indicated the resident had diagnoses of anxiety and psychotic disorder. Record review of Resident 19's admission Record with a printed dated of 6/28/23, revealed the resident was admitted on [DATE] with diagnoses of anxiety and unspecified psychosis not due…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview the facility failed to: 1) provide ongoing monitoring and assessment; 2) implement assessed interventions; and 3) obtain changes in treatment when the condition of the pressure ulcer declined for 1 (Resident 17) of 1 sampled resident. The facility census was 30. Findings are: A. Record review of the facility policy and procedure titled Documentation of Wound Treatments with a reviewed date of 2/23 revealed the facility was to complete accurate documentation of wound assessments and treatments to include response to treatments, change in condition and need for a change in treatment. Wound assessments were to be documented upon admission, weekly and as needed if there was a deterioration of the wound condition. The following was to be documented as part of a complete wound assessment: -type of wound (pressure, injury or surgical) and the anatomical location; -pressure injury stage (staging system is a method of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interviews, the facility failed to ensure 2 residents (Resident 16 and 27) were tested for Covid-19 when symptoms were identified and failed to prevent potential cross contamination when staff did not wear a face mask while testing Residents 16 and 27 for Covid-19. The sample size was 18 and the facility census was 30. Findings are: A. Record review of the facility policy Covid-19 updated 6/2023, revealed the following: -facility staff conduct active daily surveillance for new respiratory illnesses; -signs and symptoms of Covid-19 are: fever, cough, fatigue, weakness, shortness of breath, sore throat, productive cough, headache, diarrhea, congestion/runny nose and/or new onset of loss of taste or smell; and -if Covid-19 is suspected the resident will be placed on isolation precautions and tested for Covid-19 infection. B. Record review of the facility policy Covid-19 Testing Policy updated 6/2023, indicated residents would be screened for signs and symptoms of Covid-19 daily and testing would be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-06-27 · tag F0606 — failed to not employ staff found guilty of abuse — widespreadNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview; the facility failed to complete the required state Nurse Aide registry checks for 2 of 5 sampled employees to prevent potential abuse/neglect of residents. This had the potential to affect all residents. The facility census was 33. Findings are: A. Review of the facility policy Abuse, Neglect, Misappropriation and Exploitation with a review date of 1/2024 revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Further review revealed the facility must not employ or otherwise engage individuals who: -have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; -have had a finding entered in the state Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WAKEFIELD CARE CENTER | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2025 |
| BRENN, EMMA | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2022 |
| CRAIG, JILL | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2021 |
| HAGLUND, TIM | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2022 |
| KUMM, JULIE | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2023 |
| MEYER, KARLENE | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2024 |
| MILLER, WARREN | Individual | MANAGING CONTROL - GOVERNING BODY | since 03/25/2025 |
| NIXON, GINGER | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2021 |
| PRESTON, BARB | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2022 |
| RISCHMUELLER, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY | since 10/01/2023 |
| DOBBINS, MELISSA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2023 |
| HAGLUND, TRACI | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/13/2020 |
| FISCHER, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/07/2019 |
| MILLER, KAYLA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 07/06/2020 |
CMS files one row per role, so the 21 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285209. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-22, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.