Chimney Rock Villa

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 285260 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 A record review of the facility's QAPIP reports from 11/18/2024 revealed an attached incidents list. The incident list revealed six falls had occurred in October 2024. There was no evidence that falls had been Level of Harm - Minimal harm or identified as a potential concern, or a corrective action plan had been developed or implemented. potential for actual harm

A record review of the facility's QAPIP reports revealed no evidence of QAPI meeting minutes for December Residents Affected - Many 2024.

A record review of the facility's QAPIP reports from 1/20/2025 revealed no evidence that falls had been discussed or identified as a potential concern.

A record review of the facility's QAPIP reports from 2/17/2025 revealed no evidence that falls had been discussed or identified as a potential concern.

A record review of the facility's QAPIP reports from 3/17/2025 revealed an attached incidents list. The incident list revealed five falls had occurred in February 2025. There was no evidence that falls had been identified as a potential concern, or a corrective action plan had been developed or implemented.

An interview on 3/25/2025 at 10:30 AM with the Nursing Home Administrator (NHA) revealed their QAPIP team meets monthly, and each department head goes through their negative trends of identified concerns,

these issues are then discussed. The QAPIP team decided of which identified concerns to work on by any negative trends and by severity level for potential harm outcomes to the residents. The NHA also revealed

the QAPIP team identified falls were trending negatively at last months meeting, but did not develop or implement a corrective action plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 285260