Chimney Rock Villa
Chimney Rock Villa in Bayard, NE — inspection on March 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F689 and implement plans of action to identify and correct the deficient practice.
This had the potential to affect all residents that reside within the facility.
The facility identified a census of 24.
Findings are:
A record review of a facility policy, Quality Assurance and Performance Improvement Program with a revised date of February 2020, revealed the objectives of the QAPIP are to: 1) Provide a means to measure current and potential indicators for outcomes of care and quality of life, 2) provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, 3) reinforce and build upon effective systems and processes related to the delivery of quality care and services, and 4) establish systems through which to monitor and evaluate corrective actions.
The key components of the QAPI plan are as follows:
a.
Tracking and measuring performance.
b.
Establish goals and thresholds for performance measurement.
c.
Identifying and prioritizing quality deficiencies.
d.
Systematically analyzing underlying causes of systemic quality deficiencies.
e.
Developing and implementing corrective action or performance improvement activities.
f.
Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.
Record reviews and interviews during the complaint survey conducted on 3/20/2025-3/25/2025 revealed a negative trend of falls, including some with major injuries from 9/26/2024-2/19/2025.
A record review of the facility's QAPIP reports from 9/16/2024 revealed an attached incidents list.
The incident list revealed two falls had occurred in August 2024.
A record review of the facility's QAPIP reports from 10/21/2024 revealed an attached incidents list.
The incident list revealed six falls had occurred from 9/18/2024-10/18/2024.
There was no evidence that falls had been identified as a potential concern, or a corrective action plan had been developed or implemented.
285260
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 285260 B.
Wing 03/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Chimney Rock Villa 106 East 13th Street Bayard, NE 69334
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.