Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wauneta Care And Therapy Center during CMS and state inspections, most recent first.
A nurse aide did not complete the required 12 hours of annual continuing education, instead receiving only 2.85 hours during the relevant period, as confirmed by facility records and the Facility Administrator.
The facility did not ensure that residents received required visits from a physician during initial and subsequent recertification periods, instead relying on PAs and APRNs to perform these visits. Multiple residents with complex medical conditions were only seen by non-physician practitioners, and in some cases, there was no evidence of any physician evaluation during their stay. The DON confirmed that physicians were not routinely involved in resident care as required.
A resident was admitted with admission orders written and signed only by a physician assistant, without a physician's co-signature or recommendation for nursing home placement. The DON confirmed that the resident was not followed by a physician and that no physician documentation was present in the medical record, despite the resident having multiple complex medical conditions.
A resident with dementia, anxiety, and other conditions was prescribed multiple psychotropic medications, but the facility did not attempt a gradual dose reduction (GDR) or document a physician rationale for not doing so. Review of records and interviews with the DON confirmed the absence of GDR attempts or related documentation.
Two residents received acetaminophen outside the prescribed administration times, with one dose given early and another given late by an LPN. These timing errors resulted in a medication error rate of 6.5%, exceeding the allowable 5% threshold as confirmed by the DON and facility policy.
The facility failed to identify and treat a resident's pain, who had dementia and exhibited non-verbal indicators of pain. Staff misinterpreted the resident's behaviors as agitation or anxiety, and did not use appropriate pain assessment tools. The resident's care plan did not specifically address their potential for pain, leading to inadequate pain management.
The facility failed to submit their PBJ data for Q1 2024, covering 10/1/2023 through 12/31/2023. An AA responsible for the submission was locked out of the system after entering an incorrect password too many times on the due date, affecting all 32 residents.
The facility failed to ensure that a Nurse Aide completed the required 12 hours of ongoing training per year. A review of the aide's training records revealed only 2.85 hours of training in the past 12 months, confirmed by the Administrative Assistant. This deficiency had the potential to affect all 32 residents in the facility.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Residents with conditions such as dementia, heart failure, COPD, diabetes, and pressure ulcers had care plans that did not adequately address their specific needs, as confirmed by interviews with the DON and MDS Nurse.
The facility failed to follow infection control protocols, including the use of PPE and hand hygiene. A nurse aide did not wear a gown during catheter care for a resident requiring enhanced barrier precautions. Additionally, a medication aide did not perform hand hygiene between residents and handled medication with bare hands.
The facility failed to ensure that PRN psychotropic medications were reviewed and reordered every 14 days for a resident receiving telemedicine psychiatric care. Despite improvements in the resident's mental health, the PRN order for Clonazepam was not renewed as required by the facility's policy, leading to a significant deficiency in medication management.
The facility failed to ensure that medications that should not be crushed were not crushed, resulting in a medication error rate of 16.67%. A Medication Aide crushed multiple medications for a resident without proper instructions or awareness, despite the facility's policy and guidelines indicating these medications should not be crushed.
Failure to Provide Required Continuing Education for Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide received the required minimum of 12 hours of continuing education within the annual period based on the aide's employment date. According to facility policy, nurse aides must complete at least 12 hours of in-service training annually, calculated from their hire date. Record review showed that one nurse aide, hired on 2/1/22, completed only 2.85 hours of continuing education during the period from 2/1/24 to 2/1/25. This was confirmed by the Facility Administrator, who acknowledged that the nurse aide did not meet the required training hours for the specified period.
Failure to Ensure Required Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician during the required initial 30-day visit and at a minimum of every other visit, as mandated. Record reviews and interviews revealed that for six residents, physician visits were either not conducted or were substituted with visits by physician assistants (PAs) or advanced practice registered nurses (APRNs), who are not physicians. The Director of Nursing (DON) confirmed a misunderstanding regarding the requirements, believing that PAs or APRNs could perform all 60-day certifications and that the terms 'primary care physician' and 'primary care practitioner' were used interchangeably in the facility, despite acknowledging that they are not the same. For several residents, including those with complex medical histories such as chronic obstructive pulmonary disease, congestive heart failure, Alzheimer's disease, chronic kidney disease, and recent surgeries, medical records showed that recertification and routine visits were consistently performed by non-physician practitioners. In some cases, there was no evidence that a physician had evaluated the resident at any point during their stay. For example, one resident with multiple chronic conditions was only seen by a PA for all recertification visits, and another resident with Alzheimer's and chronic kidney disease had no record of ever being evaluated by a physician while in the facility. Additionally, documentation for other residents indicated that initial and subsequent required visits were completed by APRNs, with no physician involvement documented. In some instances, the facility's electronic health records incorrectly listed non-physician practitioners as the resident's physician. Interviews with the DON confirmed that these practices were routine and that physicians did not routinely see residents as required, resulting in non-compliance with federal regulations regarding physician oversight and resident care.
Failure to Obtain Physician Admission Orders for Resident
Penalty
Summary
The facility failed to ensure that all residents admitted had a written recommendation or written orders from a physician, as required by licensure regulations. Specifically, for one resident who was admitted, the admission orders were written and signed solely by a physician assistant (PA), without a co-signature or involvement from a physician (MD). Review of the resident's medical record confirmed that there was no documentation from a physician recommending nursing home placement or signing the admission orders. Interviews with the Director of Nursing (DON) confirmed that the resident's primary care provider was the PA, and that the resident was not followed by a physician. The DON acknowledged that after reviewing the medical records, there was no evidence of physician involvement in the admission process. The resident in question had multiple complex medical diagnoses, including status post left hip replacement with complications, chronic right hip hardware infection, long-term antibiotic use, hypertension, history of blood clots, anticoagulation, muscle weakness, anxiety, and overactive bladder.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) were attempted for a resident receiving psychotropic medications. Record review showed that the resident, who had diagnoses including renal insufficiency, Alzheimer's dementia, anxiety disorder, and adjustment disorder, was prescribed multiple psychotropic medications such as buspirone, mirtazapine, and sertraline. The resident exhibited behaviors such as delusions, verbal and physical outbursts, rejection of care, wandering, and urinary incontinence, and was unable to participate in a Brief Interview for Mental Status exam. Despite these conditions and ongoing use of psychotropic medications, there was no evidence in the medical record that a GDR had been attempted in the past year. Additionally, there were no physician orders or documented rationales indicating that a GDR was contraindicated for this resident. Interviews with the DON confirmed that no documentation of a GDR or physician rationale for not attempting a GDR could be found for this resident.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. Out of 31 observed medication administration opportunities, there were 2 medication errors, resulting in an error rate of 6.5%. The errors involved two residents. In the first instance, a resident was administered acetaminophen earlier than the scheduled time of 9:00 AM, as per their preference, rather than at the time ordered. In the second instance, another resident received acetaminophen later than the scheduled administration time of 7:00 AM. Both errors were confirmed through observation and staff interviews. Facility policy requires adherence to the Five Rights of Medication Administration, which include giving the right drug to the right resident, in the right amount, at the right time, and by the right route. The Director of Nursing confirmed that medications must be administered within one hour before or after the scheduled time, and deviations from this window are considered medication errors. The observed errors occurred outside of this acceptable time frame, directly contributing to the facility's medication error rate exceeding the regulatory threshold.
Failure to Identify and Treat Resident's Pain
Penalty
Summary
The facility failed to identify and treat the pain of Resident 19, who had a history of dementia and exhibited non-verbal indicators of pain. Despite the facility's policy to observe for non-verbal indicators and use appropriate pain assessment tools, the staff did not adequately assess or address the resident's pain. The resident's care plan did not specifically address their potential for pain, and the staff frequently misinterpreted the resident's behaviors as agitation or anxiety rather than potential pain indicators. Observations revealed that Resident 19 exhibited signs of pain, such as facial grimacing, repetitive distressed vocalizations, and holding their forehead. Despite these clear indicators, staff members did not ask the resident about their pain or use an appropriate pain assessment tool. Instead, the staff focused on managing the resident's agitation with psychotropic medications and non-medication interventions like providing a quieter environment and playing soft music. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN)-G confirmed that the facility used the FACES pain scale or a 0-10 pain rating scale, which were not suitable for residents with cognitive impairments like Resident 19. The facility did not have an alternative pain assessment tool for cognitively impaired residents, leading to inadequate pain management for Resident 19. The DON acknowledged that the resident's behavioral symptoms persisted despite frequent use of psychotropic medications, indicating that the root cause of the resident's distress, likely pain, was not being addressed.
Failure to Submit PBJ Data for Q1 2024
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data for the first quarter of fiscal year 2024, covering the period from 10/1/2023 through 12/31/2023. This deficiency was identified through a record review of the PBJ report from CMS, which revealed no direct care nursing staff data was submitted for the specified period. An interview with the Administrative Assistant (AA) confirmed that the AA, who was responsible for submitting the PBJ data, did not submit the data due to being locked out of the system after entering an incorrect password too many times on the evening of the due date. This failure had the potential to affect all 32 residents residing within the facility.
Failure to Ensure Required Ongoing Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA)-H completed the required 12 hours of ongoing training per year. A review of NA-H's training records on the Relias online training program revealed that NA-H had only completed 2.85 hours of training in the past 12 months. This included two 0.5-hour courses and five courses totaling 1.85 hours, all completed on a single day. An interview with the Administrative Assistant confirmed that NA-H had not attended any in-person facility in-services over the last twelve months. This deficiency had the potential to affect all 32 residents in the facility.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident 19, who had dementia and cognitive impairments, exhibited non-verbal signs of pain, but the care plan did not include interventions for pain management. Despite receiving multiple psychotropic medications and PRN pain medication, the resident's behavioral symptoms persisted, indicating that the root cause of the problem was not addressed. Interviews with the DON and an LPN confirmed the lack of appropriate pain assessment tools for cognitively impaired residents and the inadequacy of the care plan in addressing the resident's pain management needs. Resident 23, admitted with heart failure, COPD, hypertension, and edema, had a care plan that did not address these medical conditions or the use of anticoagulants and diuretics. The MDS Nurse confirmed that the care plan was not comprehensive and failed to address the resident's medical conditions. Similarly, Resident 26, who had severe cognitive impairment and Type 1 Diabetes, had a care plan that did not focus on diabetes management or insulin use. The MDS Nurse acknowledged that all care plans needed improvement to be comprehensive. Resident 32, admitted with pressure ulcers and arterial stasis ulcers, had a care plan that did not address these conditions. The MDS Nurse and DON confirmed that the care plan lacked information regarding the resident's pressure ulcers and arterial stasis ulcers. The failure to include these critical medical conditions in the care plans highlights the facility's deficiency in developing and implementing comprehensive care plans for its residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) and hand hygiene. During an observation, a nurse aide did not don a gown while providing catheter care to a resident who required enhanced barrier precautions. The resident had a left hip fracture and hydronephrosis and required maximal assistance with toileting hygiene. Despite a sign on the resident's door indicating the need for enhanced barrier precautions, the nurse aide only wore gloves and not a gown, which was confirmed during an interview with the aide. Additionally, the facility failed to ensure proper hand hygiene and medication handling during medication passes. A medication aide did not perform hand hygiene before starting a medication pass for another resident and used bare hands to handle medication without gloves. The aide also touched their hair and did not perform hand hygiene before continuing with the medication pass. These actions were observed and confirmed during an interview with the medication aide, who acknowledged the lapses in hand hygiene and proper medication handling procedures.
Failure to Review and Reorder PRN Psychotropic Medications Every 14 Days
Penalty
Summary
The facility failed to ensure that all psychotropic medications given on a PRN basis were reviewed and reordered every 14 days for Resident 32. Resident 32, who was admitted to the facility after being discharged from the hospital, was receiving telemedicine psychiatric care every two weeks. Despite the improvement in Resident 32's mental health, the facility did not adhere to the policy requiring a 14-day renewal order for PRN psychotropic medications. Specifically, the medication Clonazepam, prescribed for anxiety, was not reviewed and reordered every 14 days as required by the facility's policy and procedure for the use of psychotropic medications. Interviews with various staff members, including the Social Services Director, Minimum Data Set Nurse, Infection Control Nurse, and Director of Nurses, confirmed that Resident 32 was receiving psychiatric care via telemedicine and had shown significant improvement. However, the record reviews revealed that the PRN order for Clonazepam, which started on 1/09/2024, did not have a stop date and was not renewed every 14 days. The medication administration records for February and March 2024 showed multiple instances where Resident 32 received Clonazepam without the required 14-day renewal order. The facility's policy dated 1/24/2024 clearly states that all psychotropic drugs used on a PRN basis must be documented with a specific condition, limited to 14 days, and require the prescribing practitioner to document the rationale and duration in the medical record. Despite this policy, the facility failed to ensure compliance, as evidenced by the lack of 14-day renewal orders for Clonazepam in Resident 32's records. This oversight was identified through multiple telemedicine visit records and medication administration records, highlighting a significant deficiency in the facility's medication management practices.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications that should not be crushed were not crushed for one of the sampled residents, leading to a medication error rate of 16.67%, which is significantly higher than the acceptable threshold of 5%. Specifically, Resident 16, who was admitted with diagnoses including atrial fibrillation, heart failure, hypertension, gastro-esophageal reflux disease, iron deficiency, and overactive bladder, had multiple medications crushed by a Medication Aide (MA)-B. These medications included ferrous sulfate, pantoprazole, potassium chloride, solifenacin, and carvedilol, all of which were listed as medications that should not be crushed according to the Institute for Safe Medication Practices document. The facility's policy on medication administration, last revised on 9/13/2023, also explicitly stated that slow-release or enteric-coated medications should not be crushed, yet this policy was not adhered to in this instance. An observation on 5/14/2024 revealed that MA-B crushed Resident 16's medications without proper instructions or awareness of which medications could not be crushed. During interviews, MA-B confirmed the lack of specific instructions in the computer system and admitted to being unaware of the medications that should not be crushed. This oversight and lack of proper training or information led to the medication error, highlighting a significant lapse in the facility's medication administration process and adherence to established policies and guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wauneta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imperial Manor Nursing Home | 16 mi | ★★★★★ | 7 | 0 |
| Sarah Ann Hester Memorial Home | 26.6 mi | ★★★★★ | 7 | 0 |
| Western Sky Community Care Center Inc | 35.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.