Cycle 1
Health 2025-07-22 · Fire 2025-07-22
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Wakefield, NE
Wakefield Health Care Center
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
306 Ash Street, Wakefield, NE
(402) 287-2244
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
40
Certified beds
Average residents
28
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-06-01
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
0.84
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.92
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
5.21
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.89
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
5.70
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
617
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0203
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
6.84
Baseline 38.89% · Performance 35.71% · Measure score 6.84 · Achievement 6.84 · Improvement 1.76
Adjusted total nurse staffing
6.45
Baseline 4.40 hours · Performance 4.91 hours · Measure score 6.45 · Achievement 6.45 · Improvement 3.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 0% · Lower 95% interval 5.86% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.55 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.54% |
8.2%
5.3 pts better
|
Numerator 13 · Denominator 96 |
| Staff flu vaccination coverage | 82.35% |
42%
40.3 pts better
|
Numerator 84 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.8 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · 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 | 8.7% |
4.5%
4.2 pts worse
|
3.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.7% · Q3 6.5% · Q4 3.1% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.4%
3.5 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.3%
1.6 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 9.1% · Q3 8.3% · Q4 8.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.8% |
19.5%
1.7 pts better
|
19.6%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 13.0% · Q3 12.0% · Q4 29.2% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.3% |
21.6%
4.7 pts worse
|
16.7%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 31.8% · 4Q avg 26.3% · 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 | 24.2% |
20.4%
3.8 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.4% |
19.9%
6.5 pts worse
|
14.9%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 27.3% · Q3 33.3% · Q4 21.7% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.6%
0.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.9%
0.7 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 11.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
26.6%
0.3 pts better
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 17.3% · Q3 28.3% · Q4 34.0% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.3%
1.9 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.6% · Q3 0.0% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
80.5%
15.3 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · 4Q avg 95.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.4%
1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.9%
24.1 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-22
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 2025-09-08
F · Potential for more than minimal harm
2024-06-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-06-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-06-27
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-07-30
E · Potential for more than minimal harm
2023-06-29
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-07-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-07-22
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-30
E · Potential for more than minimal harm
2024-06-27
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 2024-08-30
E · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-06-27
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 2024-08-30
D · Potential for more than minimal harm
2024-06-27
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 2024-08-30
D · Potential for more than minimal harm
2024-06-27
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 2024-08-30
D · Potential for more than minimal harm
2024-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-06-27
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-08-30
C · Minimal harm
2024-06-27
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-08-30
D · Potential for more than minimal harm
2023-06-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Dobbins, Melissa
Operational/Managerial Control · Individual
Dobbins, Melissa
Corporate Director · Individual
Fischer, Amanda
Operational/Managerial Control · Individual
Haglund, Traci
Operational/Managerial Control · Individual
Haglund, Traci
Corporate Director · Individual
Miller, Kayla
Operational/Managerial Control · Individual
Wakefield Care Center
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Wayne, NE
1-star overall rating with 1-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Heritage of Emerson
Emerson, NE
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Wisner Care Center
Wisner, NE
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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