Wakeeney, KS

Trego Co-Lemke Memorial Hospital Ltcu

4-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle

320 N 13th St, Wakeeney, KS

(785) 743-2182

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1974-03-31

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.69

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

1.00

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

3.14

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.83

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.68

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

4.03

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.89

CMS adjusted RN staffing hours

Adjusted total hours

6.23

CMS adjusted total nurse staffing hours

Case-mix index

1.06

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 50% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.8 0.3 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.4	2.2 0.2 pts worse	1.8 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.4%	91.8% 3.6 pts better	93.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 96.9% · Q3 96.9% · Q4 93.9% · 4Q avg 95.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.5% 4.5 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	2.3%	4.4% 2.1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.1% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.9%	5.6% 4.7 pts better	11.4% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9%
Percentage of long-stay residents who lose too much weight	5.5%	5.0% 0.5 pts worse	5.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.7% · Q3 6.2% · Q4 6.2% · 4Q avg 5.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.2%	23.2% 2 pts worse	19.6% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 23.3% · Q3 21.9% · Q4 21.9% · 4Q avg 25.2%
Percentage of long-stay residents who received an antipsychotic medication	26.5%	19.8% 6.7 pts worse	16.7% 9.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.8% · Q3 28.0% · Q4 34.8% · 4Q avg 26.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	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	14.2%	18.4% 4.2 pts better	16.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 4.3% · Q3 21.1% · Q4 15.1% · 4Q avg 14.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.3%	18.8% 0.5 pts worse	14.9% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.9% · Q3 26.7% · Q4 13.3% · 4Q avg 19.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	4.7%	1.8% 2.9 pts worse	1.0% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.6% · Q3 3.5% · Q4 4.8% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.8%	3.1% 0.7 pts worse	1.7% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.2% · Q4 9.1% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.7%	23.2% 8.5 pts better	19.8% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 15.5% · Q3 11.1% · Q4 11.2% · 4Q avg 14.7%
Percentage of long-stay residents with pressure ulcers	5.8%	4.6% 1.2 pts worse	5.1% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 9.2% · Q3 9.5% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.8%	75.6% 6.2 pts better	81.7% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 81.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-04 · Fire 2025-06-04

9 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2023-09-20 · Fire 2023-09-20

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

13 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)

Cycle 3 Health 2022-05-26 · Fire 2022-05-26

1 health deficiencies

Top issue: Infection Control (1 deficiency)

15 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-04

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2025-07-30

F · Potential for more than minimal harm 2025-06-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-07-30

F · Potential for more than minimal harm 2025-06-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-30

F · Potential for more than minimal harm 2025-06-04

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-30

F · Potential for more than minimal harm 2025-06-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-30

E · Potential for more than minimal harm 2025-06-04

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-07-30

E · Potential for more than minimal harm 2025-06-04

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-07-30

E · Potential for more than minimal harm 2025-06-04

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2025-07-30

E · Potential for more than minimal harm 2025-06-04

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-07-30

E · Potential for more than minimal harm 2025-06-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-07-30

D · Potential for more than minimal harm 2025-06-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-07-30

D · Potential for more than minimal harm 2025-06-04

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-07-30

D · Potential for more than minimal harm 2025-06-04

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-07-30

F · Potential for more than minimal harm 2023-09-20

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-11-02

F · Potential for more than minimal harm 2023-09-20

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-11-02

F · Potential for more than minimal harm 2023-09-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-11-02

F · Potential for more than minimal harm 2023-09-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-02

F · Potential for more than minimal harm 2023-09-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-11-02

F · Potential for more than minimal harm 2023-09-20

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 2023-11-02

F · Potential for more than minimal harm 2023-09-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2023-11-02

E · Potential for more than minimal harm 2023-09-20

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-11-02

F · Potential for more than minimal harm 2022-05-26

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-07-27

F · Potential for more than minimal harm 2022-05-26

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-09-23

F · Potential for more than minimal harm 2022-05-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-07-27

F · Potential for more than minimal harm 2022-05-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-07-16

F · Potential for more than minimal harm 2022-05-26

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2022-07-28

F · Potential for more than minimal harm 2022-05-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-09-23

E · Potential for more than minimal harm 2022-05-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-07-16

E · Potential for more than minimal harm 2022-05-26

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 2022-07-25

E · Potential for more than minimal harm 2022-05-26

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2022-07-21

E · Potential for more than minimal harm 2022-05-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-07-21

E · Potential for more than minimal harm 2022-05-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-08-11

E · Potential for more than minimal harm 2022-05-26

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2022-07-16

E · Potential for more than minimal harm 2022-05-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-07-18

D · Potential for more than minimal harm 2022-05-26

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-07-19

D · Potential for more than minimal harm 2022-05-26

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2022-07-22

Inspection history

Recent health citations

J · Immediate jeopardy 2025-11-19

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-11-17

F · Potential for more than minimal harm 2025-06-04

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2025-07-18

F · Potential for more than minimal harm 2025-06-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-18

E · Potential for more than minimal harm 2025-06-04

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-04

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-04

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-04

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-04

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-07-18

D · Potential for more than minimal harm 2023-09-20

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F758 · Pharmacy Service Deficiencies

Health

Implement 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.

Corrected 2023-10-05

D · Potential for more than minimal harm 2023-09-20

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2023-10-05

C · Minimal harm 2023-09-20