Cycle 1
Health 2025-06-12 · Fire 2025-06-12
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Oakland, NE
Oakland Heights
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
207 South Engdahl Avenue, Oakland, NE
(402) 685-5683
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
37
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,630
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9964
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.71
Baseline 32.50% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
3.98
Baseline 4.22 hours · Performance 4.21 hours · Measure score 3.98 · Achievement 3.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.84% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 5.42% |
| Discharge to community | 52.5% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 50% · Lower 95% interval 36.93% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | 45% |
53.69%
8.7 pts worse
|
Numerator 9 · Denominator 20 |
| Discharge mobility score | 55% |
50.94%
4.1 pts better
|
Numerator 11 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18.99% |
8.2%
10.8 pts better
|
Numerator 15 · Denominator 79 |
| Staff flu vaccination coverage | 44.68% |
42%
2.7 pts better
|
Numerator 63 · Denominator 141 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 12 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.0
0.5 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.4%
3.6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.3%
1.9 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 0.0% · Q4 6.7% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
19.5%
7.4 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.9% · Q3 12.5% · Q4 19.4% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
21.6%
2.4 pts better
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 13.6% · Q3 22.7% · Q4 25.9% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
20.4%
1.4 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.6% |
19.9%
5.7 pts worse
|
14.9%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 22.2% · Q3 22.6% · Q4 38.7% · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.9%
1.6 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 8.8% · Q4 2.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
26.6%
3.1 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 35.7% · Q3 36.8% · Q4 22.7% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
4.3%
3.7 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.5%
19.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
11.6%
2.7 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 12.5% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 12.1% |
2.4%
9.7 pts worse
|
1.6%
10.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
20.9%
4.7 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 12.5% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-08-15 · Fire 2023-08-15
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-27
E · Potential for more than minimal harm
2025-06-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-27
E · Potential for more than minimal harm
2025-06-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-27
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-29
F · Potential for more than minimal harm
2024-06-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-29
F · Potential for more than minimal harm
2023-08-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-27
D · Potential for more than minimal harm
2023-08-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-08-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-24
Penalties and ownership
What sits behind the stars
Ownership
City Of Oakland Ne
5% Or Greater Indirect Ownership Interest · Organization
Dodd-Lundquist, Roxanne
Operational/Managerial Control · Individual
Heppner, Nichole
Operational/Managerial Control · Individual
Johnson, Kelli
Operational/Managerial Control · Individual
Martin, Tracie
Operational/Managerial Control · Individual
Nelson, Karen
Operational/Managerial Control · Individual
Phillips, Brittani
Operational/Managerial Control · Individual
Rohrs, Rachel
Operational/Managerial Control · Individual
Shockley, Garrett
Operational/Managerial Control · Individual
Yeutter, Joshua
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Joseph's Hillside Villa
West Point, NE
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Accura HealthCare of Tekamah
Tekamah, NE
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Colonial Haven
Beemer, NE
4-star overall rating with 5-star inspections with $4,580 in total fines with 3 fire-safety deficiencies in the latest cycle
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