Community Memorial Health Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(D)Based on record review, observation, and interview, the facility failed to obtain temperatures for all food items prepared by the dietary department and ensure that temperatures of food or drink items were at a palatable safe level. This had the potential to affect all of the residents' receiving food or drink items from the dietary department. The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11Based on observation, record review, and interview, the facility failed to ensure hair restraints were worn to keep hair from possibly contacting food and food service items and failed to utilize the approved technique when completing hand hygiene during meal preparation. This had the potential to affect all of the resident's receiving food from the kitchen. The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (D&E)Based on interview and record review, the facility failed to ensure resident and resident POA (Power of attorney who can make decisions for Resident if Resident is unable)/or their personal representative was informed of the risks and alternate treatment available before initiating antipsychotic/psychotropic medications (medications used to treat psychotic/behavior disorders). This affected 4 of 5 sampled residents (Residents 41, 4, 7, and 24), and the facility failed to notify the resident POA when a change in skin condition occurred for 1 resident (Resident 24). The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i)Licensure Reference Number 175 NAC 1-005.026(D)Based on observation, record review, and interview the facility failed to ensure that staff performed hand sanitization (hand hygiene- washing the hands using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among residents and health care personnel) between resident rooms during laundry delivery for 4 residents (Residents 54, 41,13, and 66); failed to ensure that laundry was carried in a sanitary manner to prevent the potential for cross-contamination (this had the potential to affect 15 of 15 residents); and failed to ensure that gloves were changed between contaminated surfaces and hand hygiene between glove changes for 1 resident. (Resident 17). The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(E)Based on record review and interviews, the facility failed to ensure residents and or family members had a method to file grievances anonymously and were provided on information on how to file grievances anonymously. This had the potential to affect all the residents residing in the facility. The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to ensure that a PRN (when needed) order for antipsychotics (psychiatric medications primarily used to treat psychosis, schizophrenia, bipolar disorder, and severe agitation by regulating brain 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.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i)Based on record review and interview the facility failed to ensure that a written summary of the baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed and provided to the resident/resident representative as required for 2 of 2 residents (Residents 37 and 60); and the facility failed to ensure that a baseline care plan was developed within 24 hours for 1 of 2 residents (Resident 60). This prevented the resident/resident representative from identifying additional resident needs and goals for the resident care plan. The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09Based on record review, interview, and observation, the facility failed to ensure dosing information is included in prescribed medications for 1 (Resident 17) out of 5 sampled residents. Facility census was 59. Record review of Resident 17s admission Summary Revealed an admission date of 1/12/2021 with the following diagnoses-Cervicalgia (medical term for pain localized in the neck)-Unspecified osteoarthritis, unspecified siteRecord 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). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview and record review, the facility failed to provide an environment free of accidents and hazards for 2 residents (Resident 17 and Resident 24) of 2 residents sampled. The facility census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12-00609(H)Based on record review, interview, and observation the facility failed to replace respiratory equipment for 1 resident (Resident 7) of 1 sampled resident. The facility census was 59. Record review of a facility policy titled CPAP/BiPAP (which is a non-invasive ventilator used to treat breathing difficulties by delivering pressurized air through 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. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (H) iii Based on observation, record review, and interview, the facility failed to complete skin assessments per facility policy and standards of practice for 1 resident (Resident 3), of 4 sampled residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F) Based on observation, record review, and interview; the facility failed to implement and/or revise Residents 1, 29, 54, and 59's current care plans to reflect the resident's current status. The sample size was 22 and the facility census was 58.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure meals served in the Special Care Unit (SCU) were palatable and served at the proper temperature. This had the potential to affect all 16 residents that resided on the SCU. The facility census was 58.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B), and 175 NAC 12.006.18(D) Based on observations, record review and interview: the facility staff failed to utilize gloves and to wash hands and/or perform hand hygiene at appropriate intervals during the provision of toileting and catheter cares for Residents 1, 26 and 54 and to implement enhanced barrier precautions when providing direct cares for Residents 29 and 59. The total sample size was 22 and the facility census was 58.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04(F)(i)5 Based on record review and interview; the facility staff failed to notify the primary care practitioner (PCP) and the Registered Dietician (RD) of weight loss for 2 (Residents 27 and 12) of 3 residents reviewed. The facility identified a census of 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure Level 1 Preadmission Assessment and Resident Review (PASARR-screening process required to be completed prior to admission to ensure residents with Serious Mental Illness (SMI), Intellectual Disability(ID), Development Disability(DD) or Related Disorders (RD) met the criteria for Nursing Home admission and had any additional services needed) screens were completed accurately prior to admission for Residents 48 and 44. The sample size was 3 and the facility census was 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv) Based on interview and record review; the facility failed to ensure Resident 59's Bowel and Bladder management plan was coordinated and addressed in cooperative with the Hospice Care provider. The sample size was 1 with a census of 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006. I(i) Based on observation, interview, and record review; the facility failed to ensure Residents 14 and 16's falls were reviewed for causal factors, fall prevention interventions were based on causal factors, and reviewed and revised to prevent ongoing falls. The sample size was 4 and the facility census was 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotics were given in accordance with the facility Antibiotic Stewardship Program (ASP-program for optimizing treatment of infections and reducing adverse events from the use of antibiotics) for Resident 16. The sample size was 5 and the facility census was 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A) Based on record review and interview; the facility failed to attempt a Gradual Dose Reduction (GDR) of Residents 24, 26, and 29's psychotropic medications (medications which alter consciousness, mood, and thoughts) or to have a documented clinical rationale for continued use. The sample size was 5. The facility census was 58.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility pharmacist failed to ensure emergency and immediate use medications were available. This had the potential to affect all residents in the building. The facility staff identified a census of 60.

Inspectors wroteB. Review of Resident 57's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/9/23 revealed the resident was admitted [DATE] with diagnoses of: unspecified dementia, non-Alzheimer's dementia, bipolar depression, and psychotic disorder. Resident 57 had severe cognitive impairment and displayed hallucinations and delusions. In addition, the resident had verbal behaviors directed at others, other behavioral symptoms not directed toward others (hitting or scratching self, pacing, rummaging, disrobing in public, verbal/vocal symptoms such as screaming or making disruptive sounds), the resident wandered daily and had episodes in which the resident rejected cares. Review of a Nursing Progress Note dated 7/21/23 at 4:35 PM revealed Resident 57 had attempted to have sexual interactions with another resident on the secured unit. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observations, record review and interviews; the facility failed to ensure foods were served at palatable temperatures to the residents on the secured unit. This had the potential to affect all 16 residents served in the secured unit dining room. The facility staff identified a census of 60.

Inspectors wroteLicensure Reference 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified long term care facility) was accurately coded for 1(Resident #34) of 1 sampled resident. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D5b Based on observations, record review and interview; the facility failed to provide individualized activities for 1 (Resident 55) of 2 sampled residents. The facility identified a census of 60.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09D Based on record review and interviews, the facility failed to follow a provider order for 1 (Resident #34) of 1 sampled resident. Resident #34. Facility reported census of 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assure a safe environment as the staff failed to: 1) assess causal factors and to develop and/or revise fall interventions to prevent ongoing falls for 2 ( Resident 54 and 1) and implement interventions to prevent potential choking and/or aspiration for Resident 1. The sample size was 8 and the facility census was 60.

Inspectors wroteLicensure Reference Number 12-006.09D8b Based on record review and interview; the facility failed to identify a significant weight loss and notify the Provider for 1 of 4 (Resident 21) sampled. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12.006-19D Based on record review and interview; the facility failed to ensure 1 (Resident 21) of 5 sampled resident's as needed (PRN) psychotropic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotions) medication was limited to 14 days. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10E Based on observation, record reviews, and interviews: the facility failed to ensure a medication error rate of less then 5 percent (%) which affected 2 (Residents 19 and 34) of 3 sampled residents. The medication error rate was 13.79%. The facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E1 Based on observation, record review and interview; the facility failed to provide safe storage of drugs as medications were left on top of the medication cart unattended. The total sample size was 16 and the facility census was 60.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, record review, and interview: the facility staff failed to clean a multi-resident use glucometer with Environmental Protection Agency (EPA) approved cleanser for Resident 19 and failed to perform hand hygiene to prevent potential cross contamination when performing procedures for Residents 34, 37, and 19. Facility census was 60.