Community Memorial Health Center

establish a grievance policy and make prompt efforts to resolve grievances.

facility failed to ensure residents and or family members had a method to file grievances anonymously

affect all the residents residing in the facility.

The facility census was 59.Findings are:

Record review of an undated facility policy titled Resident and Family Grievances revealed information on how to file a grievance or complaint will be available and a grievance may be filed anonymously.

Record review of an undated admission Agreement revealed in section 6 letter M the resident is encouraged to voice their grievances and suggestions to the administrator, director of nursing, social service director, or to the resident council.

There is no information provided on how to file grievance anonymously.In an interview completed on 02/26/2026 at 10:45 AM with the facility Social Services Director (SSD), the SSD confirmed that they are the facility's grievance officer.

The SSD stated that if a resident or family wished to file a grievance, they would notify a staff member, and the staff member would assist them with the process.

The SSD stated they were not sure how a resident would file a grievance anonymously unless they slid it under their office door.

The SSD confirmed the policy of the facility that contained the statement guideline that a grievance may be filed anonymously.

The SSD stated that residents and families are educated on the grievance process while completing their admission paperwork and sign off on this in the admission paperwork.

The SSD confirmed there was not education or instruction provided on how to file a grievance anonymously.In an interview completed on 02/26/2026 at 3:30 PM the Facility Administrator (FA) stated the facility had an open-door policy in regards to grievances.

The FA confirmed that residents and families are encouraged to notify facility staff with grievances.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

resident's ability to function.

failed to ensure that a PRN (when needed) order for antipsychotics (psychiatric medications primarily

neurotransmitters) were limited to 14 days and the practitioner evaluated the resident for renewal of the PRN medication.

This affected 1 resident (Resident 34) of 5 residents sampled.

The facility census was 59.

Findings are:

Record review of a facility policy titled, Use of Psychotropic Medication, dated 10/12/2025 revealed, residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).-9. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days).- a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall indicate the duration for the PRN order. A record review of Resident 34's admission Record dated 2/24/26 revealed and admission date on 1/29/26.

Further review revealed the following diagnosis for Resident 34:- dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance (cognitive decline caused by an underlying medical condition including symptoms like verbal/physical aggression, combativeness, shouting, and potential wandering)- non-st-elevation myocardial infarction (serious heart attack)- Parkinson's disease with dyskinesia, with fluctuations (a progressive neurodegenerative movement disorder involving involuntary movements (dyskinesia))-depression, unspecified (diagnosis for those experiencing significant depressive symptoms that cause distress or impairment) A record review of Resident 34's Order Summary Report dated 2/24/26 revealed an order for Zyprexa (an antipsychotic medication primarily used to treat schizophrenia, bipolar disorder, and treatment-resistant depression) oral tablet 5 milligram (mg) give 1 tablet by mouth every 6 hours as needed for agitation/outbursts related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance order date 2/6/26. An interview with the Director of Nursing (DON) and Interim Director of Nursing (IDON) on 2/26/26 at 11:00 AM confirmed no end date listed on the orders for Resident 34's PRN antipsychotic medication Zyprexa order dated 2/6/26 and confirmed there were no physician notes revealing a review of the PRN antipsychotic medication prescribed.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

on [DATE].

Diagnoses included Parkinson's Disease, visual hallucinations, and urinary tract

neck bent over and is shaky due to Parkinson's.

Record review of the Interim (baseline) Care Plan for

on [DATE]). (The baseline care plan was not developed within 24 hours as required).

The Interim Care Plan for Resident 60 revealed that it contained no documentation of resident/resident representative participation or review of the baseline care plan.

Record review of the resident medical record for Resident 60 revealed the comprehensive admission MDS assessment dated [DATE]. (Comprehensive care plan required to be developed by 11/13/25).

Record review of the Care Plan Minutes for Resident 60 dated 11/14/25 revealed that it was for the first care plan meeting after admission into the facility. (This meeting occurred after the completion of the comprehensive care plan for Resident 60.

This did not allow the resident/resident representative to participate in the development of the baseline care plan and comprehensive care plan).

Record review of the medical record for Resident 60 revealed that it contained no documentation of a written summary of the baseline care plan being provided to the resident/resident representative as required.Interview on 2/25/26 at 3:22 PM with the facility Director of Nursing (DON) confirmed that the facility is required to develop a baseline care plan within 24 hours of admission for each resident.

The DON confirmed that the facility did not complete a written summary of the baseline care plan for Resident 60 as required.

The DON revealed that the facility discusses the baseline care plan on admission with the resident and/or family but does not have them sign anything.

The DON confirmed that a written summary of the baseline care plan was not offered to the resident or representative since the facility does not complete a written summary.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

Review of Resident 17's order summary dated 2/25/2026 revealed Diclofenac Sodium External Gel 1% apply to neck, back topically every day and night shift related to primary osteoarthritis (Diclofenac Sodium Gel (or Voltaren) is a non-steroidal anti-inflammatory drug used to help relieve arthritic pain).

Record review of manufacturers instructions for Diclofenac sodium topical gel revealed The proper amount of Diclofenac gel should be measured using the dosing cards supplied in the drug product carton.

One dosing card should be used for each application of drug product.

The gel should be applied within the oblong area of the dosing card up to the2-gram or 4-gram line. total dose should not exceed 32 grams per dayObservation on 2/25/2026 at 7:29 AM of medication application of Diclofenac gel revealed LPN-E used an unmeasured amount of topical gel to apply to Resident 17's neck.

Interview on 2/26/2026 at 9:20 AM with Facility Interim Director of Nursing (IDON) confirmed that medication orders should include resident name, medication dose, time of administration, route of administration and prescriber name. IDON also confirmed that medication orders from a physician are placed in PCC by a nurse and double checked with a second nurse. IDON confirmed medication orders noted to be missing any information require notification to nursing and then to pharmacy and are to be changed to include all required information.

Review of prescription label for Diclofenac sodium topical gel for Resident 17 with IDON confirmed the label was missing dose information. IDON also confirmed that manufacturer's instructions are included in the medication box as well as the dosing card necessary for administering ordered dose.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

During the observation of the environment, the bathroom designated to be used by Resident 17 and Resident 24 was found to contain the following prescribed medications:- Diclofenac Sodium External Gel 1 % (percent) (Topical) prescriber order date 11/26/25- Eucerin External Cream (Skin Protectant) Apply to feet topically prescriber order date 11/26/25- Miconazole Nitrate Powder (Topical) Apply to abdominal folds topically prescriber order date 2/5/24- Triamcinolone Cream to red/patchy areas to right and left hands twice a day (BID) prescriber order date 2/4/25 A record review for Resident 17 revealed no Self Administration of Medication (SAM; self-administration is the process where a patient independently prepares and takes their own medication, including oral, topical, or injections without direct staff assistance) on file for the previously listed medications. A record review for Resident 24 revealed no SAM on file for the previously listed medications. An interview with the facility DON (Director of Nursing) and the IDON (Interim Director of Nursing) on 2/26/26 at 11:00 AM confirmed medications should be locked in the medication cart and/or locked in the nurse office in the secure unit.

Further interviews confirmed that all medications, creams, powders and topicals prescribed from a practitioner are not to be left out under any circumstance.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

The facility census was 59.

Record review of a facility policy titled CPAP/BiPAP (which is a

mask) Cleaning dated 02/25/2026 revealed it was the policy of the facility to replace equipment routinely to prevent the occurrence or spread of infection.

The face mask and tubing should be replaced once every three months and the head gear, non-disposable filters, and humidifier once every six months.

Record review of an admission Record revealed the facility admitted Resident 7 on 06/14/2023 with diagnosis of obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts because throat muscles relax, causing the airway to collapse during sleep).Record review of Resident 7's Order Summary on 02/25/2026 revealed Resident 7 had a provider order for a BiPAP to be applied every night.In an interview completed on 02/23/2026 at 10:50 AM with Resident 7, Resident 7 stated that they utilize a BiPAP every night when they sleep.

The resident stated that staff provide care and maintenance of the equipment due to the resident not being able to self-manage the tasks.

The resident stated they are not sure when their equipment (Mask, Tubbing, and Filters) get changed or replaced.

The resident stated the mask that they were using was the same mask they received at the appointment when they received the equipment and had not been changed to their knowledge.

Record review of a document titled Diagnostics & Consultants and dated 10/02/2025 revealed for supplies (needed to be replaced): Water chamber every 6 months, Tubing every 3 months, and face mask every 3 months.In an observation completed on 02/23/2026 at 10:50 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on there bed with the mask lodged between the mattress of the bed and the 1/4 side rail attached to the bed.In an observation completed on 02/24/2026 at 9:50 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on their bed.

The mask was observed to be cloudy with dried white spots visible on the mask.In an observation completed on 02/25/2026 at 8:15 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on their bed with the mask lodged between the mattress of the bed and the 1/4 side rail attached to the bed.In an interview completed on 02/25/2026 at 8:20 AM with Licensed Practical Nurse E (LPN-E), LPN-E stated that the central supply staff member manages the changing of the resident's respiratory equipment and how frequently it is changed. In an interview completed on 02/25/2026 at 8:21 AM with the Central Supply (CS) staff, the CS stated that they were unaware that Resident 7 utilized a BiPAP at bedtime.

The CS stated that they had not ordered or changed the resident's respiratory equipment as they were unaware of the resident using this equipment and device.In an interview completed on 02/25/2026 at 3:45 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 7's respiratory equipment had not been changed as outlined in the facility policy or as recommended by the residents provider as outlined in the Diagnostics and Consultants form.

refilled the pitchers with more juice and placed them into the refrigerator to be used at the next meal.

they do not check the temperature of the drinks prior to refilling the pitchers with more of the fluids

DA-H checked the temperatures of the fluids in the pitchers, and the following results were obtained:-Apple Juice had a temperature of 45 degrees Fahrenheit-Grape Juice had a temperature of 46 degrees Fahrenheit-Orange Juice had a temperature of 46 degrees Fahrenheit-Milk had a temperature of 43 degrees Fahrenheit-Tomato Juice had a temperature of 45 degrees FahrenheitIn an observation completed on 02/24/2026 at 12:45 AM with DA-H, DA-H stated that cold items including liquids (the juice and milk) should be served/kept at 41 degrees Fahrenheit.

The DA confirmed that the fluids were not maintained at 41 degrees Fahrenheit and should have been.In an interview completed on 02/24/2026 at 12:46 AM with the Dietary Manager (DM), the DM confirmed that the fluids (juices and milk) were not maintained at the recommended temperature or lower and should have been.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

vigorously with soap for 20 seconds when completing hand hygiene and should have.In an interview

[NAME] did not complete hand hygiene using the approved method.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823

Observation on 2/25/2026 at 7:29 AM of medication pass with Resident 17 revealed the Licensed Practical Nurse-(E) (LPN-E) did not perform hand hygiene between glove changes.

Observation also revealed LPN-E applied topical medications to Resident 17 without changing gloves or performing hand hygiene after touching wheelchair, medication cart, and tablet used for charting.

Record Review of facility policy for hand hygiene revealed The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Record review of facility policy for hand hygiene revealed hand hygiene is to be performed after handling contaminated objects, before performing resident care procedures, before preparing or handling medications, when, during resident care, moving from a contaminated body site to a clean body site .

Interview on 2/26/2026 at 9:02 AM with the Infection Preventionist (IP) confirmed staff are expected to perform hand hygiene after removing dirty gloves and before donning clean gloves.

285257 02/26/2026

Community Memorial Health Center 1015 F Street Burwell, NE 68823