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Chimney Rock Villa: Unchecked Fall Crisis - NE
The facility's internal incident tracking told the story clearly....
Latest reports, citations, and penalties from CMS data
The facility's internal incident tracking told the story clearly....
The facility received a citation for **actual harm** under federal nursing home regulations....
The inspection revealed that the narcotic log book contained **no documentation that shift-to-shift counts had been completed at any time**....
Residents placed in secured units typically require that level of protection because they are at risk of wandering....
Inspectors documented a detailed, minute-by-minute account of what occurred between 4:01 PM and 4:15 PM that day....
That care plan had been in place since February 2022 and was active at the time of the incident....
He was dependent on staff for all activities of daily living and used a wheelchair....
A review of bath records revealed the resident received **zero baths** from his mid-December admission through the end of that month....
The findings raised concerns about the facility's ability to protect medically vulnerable residents from foodborne illness and infection....
Quality assurance programs serve as internal monitoring systems that track clinical outcomes, incident patterns, and care delivery metrics....
The resident, who had diagnoses including anoxic brain damage, hypertension, and disorientation, made statements to staff expressing suicidal thoughts....
On July 15, 2024, state surveyors found a resident lying in a fully reclined Geri-chair with a wheelchair wedged underneath the extended footrest....
R47 received nebulizer treatments four times daily with Ipratropium-Albuterol solution to manage chronic obstructive pulmonary disease and shortness of breath....
The deficiency resulted in severe weight loss, representing a significant decline in the resident's physical well-being....
This violation represents a critical failure in healthcare facility management....
Long-Term Care Ombudsmen serve as independent advocates who can investigate whether discharges are appropriate, voluntary, and in the resident's best interest....
On November 29, just four days after returning from psychiatric hospitalization, the resident told nursing staff "I want to die....
On March 24 at 5:20 PM, the resident was observed hitting her head on a wall near the dining room....
Staff members reported observing the male resident leaving the victim's room and adjusting his belt in the facility lobby....
## Medical Treatment Delays Beyond the behavioral care concerns, inspectors found the facility failed to provide timely medical treatment to residents....