Report
TheVardellReport
Chimney Rock Villa
Skilled nursing facility and nursing facility
106 East 13th Street
Bayard, NE 69334
Report
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The Vardell Report.Chimney Rock Villa
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Bayard, NE
- Record Period
- 2023–2025
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from August 2023 to November 2025, state surveyors documented 30 findings at Chimney Rock Villa; 30 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 7
- 2023–2025, complaint and standard
- Findings
- 30
- Deficiencies cited by state inspectors
- Corrected
- 30
- Of 30 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 5 | 0 |
| 2024 | 3 | 14 | 2 |
| 2025 | 3 | 11 | 2 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 30 of 30 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $110,988, their payment not published.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, July 30, 2025, recorded 6 findings (most serious: Level F).
What to Ask About
- Accurate Assessments, Cited in Three Inspections
- Quality of Care, Cited in Three Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
- Citation F867, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- Chimney Rock Villa
- Address
- 106 East 13th Street, Bayard, NE 69334
- CMS Certification Number
- 285260
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 49
- Ownership
- Government - City
- Record Window
- August 9, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Complaint investigation
1 finding
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Dec 16, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
6 findings
The same visit included a complaint investigation.
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Aug 13, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 13, 2025
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Aug 13, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Aug 13, 2025
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 13, 2025
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Aug 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level HActual harmCorrected Apr 9, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 9, 2025
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Apr 9, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 9, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
9 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jul 24, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Jul 24, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 24, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jul 24, 2024
Enforcement Action
Civil money penalty, $31,135 imposed March 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
3 findings
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level FNo actual harm, potential for moreCorrected May 20, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 20, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 20, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level JImmediate jeopardyCorrected Feb 19, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level GActual harmCorrected Feb 19, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
5 findings
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 2, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 2, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 2, 2023
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Sep 2, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 2, 2023
Enforcement Action
Civil money penalty, $79,853 imposed February 5, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 9, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accurate Assessments, Cited in Three Inspections
Inspectors cited F641 in August 2023, July 2024 and July 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F641 across all 7 inspections, oldest to newest - 2
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in July 2024, March 2025 and July 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F684 across all 7 inspections, oldest to newest - 3
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in August 2023 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level H (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F689 across all 7 inspections, oldest to newest - 4
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in May 2024 and July 2024. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F760 across all 7 inspections, oldest to newest - 5
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in July 2024 and July 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F812 across all 7 inspections, oldest to newest - 6
Citation F867, Cited in Two Inspections
Inspectors cited F867 in February 2024 and March 2025. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F867 across all 7 inspections, oldest to newest - 7
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2023 and May 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23242424252525F880 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in three inspections, most seriously at level D.
- 02
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level G.
- 03
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level H.
- 04
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 05
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
- 06
What changed after F867 was cited, and how do you check it now?
Citation F867: cited in two inspections, most seriously at level G.
- 07
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2025 fine, and has it been paid?
A $31,135 civil money penalty was imposed March 25, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Nebraska state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Aug 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Feb 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection May 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Mar 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Jul 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nebraska state survey agency
Inspection Nov 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 285260
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 9, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.