Saunders Medical Center
A critical access hospital in Wahoo, Nebraska 68066
1760 County Rd J, Wahoo, Nebraska 68066. (402) 443-4191.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 2 deficiencies cited in the last three years
- 16 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Sep 19, 2024: a standard inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 1 month of the last 36. Last cited Sep 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Sep 19, 2024: standard inspection2 deficiencies
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Anesthetic Risk And Evaluation
The inspectors’ words, 803 words
“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 15107 Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure an anesthesia qualified practitioner properly evaluated each patient after surgery for proper anesthesia recovery before hospital discharge for 6 of 6 outpatient surgical patients (Patients 26, 26, 28, 29, 30 and 31) reviewed. This failed practice had the potential to affect all surgical patients receiving anesthesia at the CAH. The average monthly number of surgeries with anesthesia is 49. Findings are: A. Review of Patient 26’s medical record revealed the patient had laparoscopic (operation performed in the abdomen using small incisions with the aid of a camera) cholecystecomy with intraopic cholangiogram (removal of the gallbladder and gallstones) under general (a temporary loss of feeling and a complete loss of awareness that keeps the patient from feeling pain) anesthesia on 3/19/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Respiratory Status; Cardiovascular Status; Post-op Hydration; or Airway. -Review of Patient 27’s medical record revealed the patient had a bilateral ear exam under anesthesia with cerumen (earwax) removal and an adenoidectomy (removal of the adenoids, tissue masses in the upper airway that sit behind the nose) under general anesthesia on 3/25/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Mental Status; Respiratory Status; Cardiovascular Status; Post-op Hydration; PONV (postoperative nausea and vomiting); or Airway. -Review of Patient 28’s medical record revealed the patient had a repair of R (right) distal (further away) fibular (outer of the two bones of the lower leg) fracture under general anesthesia on 4/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Mental Status; Respiratory Status; Cardiovascular Status; Post-op Hydration; PONV; or Airway. -Review of Patient 29’s medical record revealed the patient had a colonoscopy (a medical procedure that examines the inside of the colon and rectum using a long, flexible tube with a small camera attached) under MAC (Monitored Anesthesia Care, makes the patient feel relaxed and it reduces painful sensations and the awareness of pain) on 8/27/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Respiratory Status; Cardiovascular Status; Post-op Hydration; or Airway. -Review of Patient 30’s medical record revealed the patient had a T-11 (the eleventh thoracic vertebra in the body) kyphoplasty (procedure used to reduce pain in patients that have spinal fractures) under MAC on 6/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Date; Time; Mental Status; Respiratory Status; Cardiovascular Status; Post-op Hydration; PONV; Airway; Complications; Vital Signs; or CRNA (Certified Registered Nurse Anesthetist) Signature. -Review of Patient 31’s medical record revealed the patient had a hysterscopy (exam of the inside of the cervix and uterus) with dilation (cervix made larger) and curettage (removal of tissue from the inner lining of the uterus) under MAC on 9/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient’s status before discharge for the following areas: Mental Status; Respiratory Status; Cardiovascular Status; or Post-op Hydration. B. Review of the policy and procedure titled Delivery of Anesthesia Care (Last Approved Date 11/2023) stated “A post-anesthesia evaluation is to be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia. This evaluation will be completed by an Anesthesiologist or CRNA. The post-anesthesia evaluation should be documented in the “Anesthesia Pre-Op/Post-Op Documentation” form or in the progress notes and includes: D. Patient’s condition: 1. Level of consciousness, Awake and or Arousable 2. CV [cardiovascular] stability/adequate hydration 3. Pulmonary function stable 4. Airway patent and stable 5. Temperature > 96.8 6. Pain score < 4 7. Nausea/Vomiting 8. Review vital signs E. Note of any post-anesthetic complications F. Other pertinent data G. Need for follow-up/instructions”. C. Interview with the Outpatient Services Manager (9/19/24 at 1:25 PM) confirmed the above outpatient surgery medical records had “inappropriate documentation of the post anesthesia evaluations.””
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 129 words
“42 CFR 483.70(a) The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Saunders County Medical Center is a one story building of Type II (000) construction that was built in 2005 (with an attached Long Term Care with a two hour fire rated seperation) and is fully sprinklered. There is supervised smoke detection located in the corridors and all open areas to the corridor. The facility is in compliance, at this time, with Chapter 19: “Existing Health Care Occupancies” of the 2012 Edition of the NFPA: Life Safety Code.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 19, 2024 | Standard inspection | 1 deficiency cited |
| Sep 19, 2024 | Standard inspection | 1 deficiency cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 2; readmission, 0 better and 0 worse of 3.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- In CMS’s patient survey (Oct 1, 2024 to Sep 30, 2025): 68% rated it 9 or 10 out of 10, and 84% would definitely recommend it.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): pneumonia 19.2%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 17.4%. CMS gives no comparison with the national rate for them in this release.
- Emergency department patients spent a median of 94 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Dec 1, 1999.
- Ownership: government - local.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Government - Local.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 85% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Saunders County owns 100% directly since Jan 1, 1966.
- Bryan Health runs it.
- 2 owners or officers are people: Julie Rezac (managing employee (under contract)); Julie Rezac (runs it (operational or managerial control)).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Saunders County | Owns 5% or more directly | 100% | Jan 1, 1966 |
| Bryan Health | Runs it (operational or managerial control) | Jan 1, 2015 |
How does it compare nearby?
- No other hospital CMS lists is in Saunders County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.