Cycle 1
Health 2024-11-21 · Fire 2024-11-21
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Burwell, NE
Community Memorial Health Center
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1015 F Street, Burwell, NE
(308) 346-4440
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-05-01
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
0.48
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
0.96
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0050
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.8
Performance 17.82% · Measure score 7.8 · Achievement 7.8 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7.21
Performance 5.68% · Measure score 7.21 · Achievement 7.21 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.97
Performance 47.46% · Measure score 3.97 · Achievement 3.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.34
Baseline 3.54 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.08% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 5.82% |
| Discharge to community | 32.9% |
50.57%
17.7 pts worse
|
Worse than the National Rate · Eligible stays 49 · Observed rate 22.45% · Lower 95% interval 22.46% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.44% |
95.27%
0.8 pts worse
|
Numerator 34 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 17.24% |
53.69%
36.5 pts worse
|
Numerator 5 · Denominator 29 |
| Discharge mobility score | 17.24% |
50.94%
33.7 pts worse
|
Numerator 5 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.68% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 0% · Lower 95% interval 2.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 32.43% |
42%
9.6 pts worse
|
Numerator 36 · Denominator 111 |
| Discharge function score | 20.69% |
56.45%
35.8 pts worse
|
Numerator 6 · Denominator 29 |
| 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 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.5% |
92.8%
12.3 pts worse
|
93.4%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 81.8% · Q3 79.7% · Q4 88.5% · 4Q avg 80.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
96.1%
0.5 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
4.5%
1.1 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.5% · Q3 6.8% · Q4 4.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
4.4%
6.3 pts worse
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 5.8% · Q3 3.4% · Q4 8.2% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 31.7% |
5.3%
26.4 pts worse
|
5.4%
26.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 36.0% · Q3 32.7% · Q4 40.4% · 4Q avg 31.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.0% |
19.5%
10.5 pts worse
|
19.6%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 30.0% · Q3 22.6% · Q4 26.4% · 4Q avg 30.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.8% |
21.6%
14.2 pts worse
|
16.7%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 37.8% · Q3 40.9% · Q4 26.7% · 4Q avg 35.8% · 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 | 31.8% |
20.4%
11.4 pts worse
|
16.3%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 51.2% · Q3 19.0% · Q4 36.4% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
19.9%
0.4 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 29.5% · Q3 20.4% · Q4 20.8% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.7% |
1.6%
5.1 pts worse
|
1.0%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.7% · Q3 9.5% · Q4 5.6% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.9%
1 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.5% · Q3 1.7% · Q4 3.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
26.6%
1.4 pts better
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 31.3% · Q3 26.8% · Q4 30.0% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
4.3%
3.6 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.5% |
80.5%
10 pts worse
|
81.7%
11.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 54.8% · Q3 75.0% · 4Q avg 70.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
11.6%
5.9 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 20.0% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.0% |
75.9%
50.9 pts worse
|
79.7%
54.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 5.3% |
20.9%
15.6 pts better
|
23.9%
18.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 5.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-27 · Fire 2022-09-27
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-16
F · Potential for more than minimal harm
2023-10-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2023-11-25
F · Potential for more than minimal harm
2022-09-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-07
F · Potential for more than minimal harm
2022-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-18
E · Potential for more than minimal harm
2024-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-11-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-16
E · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
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 2024-12-16
F · Potential for more than minimal harm
2023-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-25
E · Potential for more than minimal harm
2023-10-18
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 2023-11-25
E · Potential for more than minimal harm
2023-10-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
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 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-18
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 2023-11-25
D · Potential for more than minimal harm
2023-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-25
D · Potential for more than minimal harm
2022-09-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-07
D · Potential for more than minimal harm
2022-09-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-07
Penalties and ownership
What sits behind the stars
Ownership
Garner, Timothy
Corporate Director · Individual
Groshans, Hayley
Corporate Director · Individual
Groshans, Hayley
W-2 Managing Employee · Individual
Groshans, Timothy
Operational/Managerial Control · Individual
Holmquist, Brenda
Corporate Director · Individual
Schere, Melissa
Corporate Director · Individual
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