Bayard, NE

Chimney Rock Villa

1-star overall rating with 1-star inspections with $110,988 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

106 East 13th Street, Bayard, NE

(308) 586-1142

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2004-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.82

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.16

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

2.25

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

3.23

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

0.98

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

3.09

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.96

CMS adjusted RN staffing hours

Adjusted total hours

3.77

CMS adjusted total nurse staffing hours

Case-mix index

1.17

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

66%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,362

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

36.47

Composite VBP score used to determine payment impact.

Payment multiplier

0.9899

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.35

Baseline 57.58% · Performance 54.05% · Measure score 2.35 · Achievement 2.35 · Improvement 0.58

Adjusted total nurse staffing

4.94

Baseline 3.79 hours · Performance 4.48 hours · Measure score 4.94 · Achievement 4.94 · Improvement 2.99

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.72%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 5.74%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	0.97	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 22 · Denominator 22
Falls with major injury	9.09%	0.77% 8.3 pts worse	Numerator 2 · Denominator 22
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 22 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	48.28%	8.2% 40.1 pts better	Numerator 14 · Denominator 29
Staff flu vaccination coverage	64.71%	42% 22.7 pts better	Numerator 44 · Denominator 68
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · 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	2.8	1.8 1 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 1.9 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.3	2.0 2.3 pts worse	1.8 2.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 3.4 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.1%	92.8% 5.3 pts better	93.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	96.1% 3.9 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	10.7%	4.5% 6.2 pts worse	3.3% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 15.4% · Q3 8.3% · Q4 10.3% · 4Q avg 10.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.0%	4.4% 1.6 pts worse	11.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 12.0% · Q3 4.3% · Q4 3.6% · 4Q avg 6.0%
Percentage of long-stay residents who lose too much weight	27.4%	5.3% 22.1 pts worse	5.4% 22 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 24.0% · Q3 22.7% · Q4 38.5% · 4Q avg 27.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.8%	19.5% 10.7 pts better	19.6% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 0.0% · Q3 8.3% · Q4 10.7% · 4Q avg 8.8%
Percentage of long-stay residents who received an antipsychotic medication	51.2%	21.6% 29.6 pts worse	16.7% 34.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 47.6% · Q3 55.0% · Q4 50.0% · 4Q avg 51.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	2.9%	0.3% 2.6 pts worse	0.1% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 4.2% · Q4 3.4% · 4Q avg 2.9%
Percentage of long-stay residents whose ability to walk independently worsened	32.6%	20.4% 12.2 pts worse	16.3% 16.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 32.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.7%	19.9% 11.8 pts worse	14.9% 16.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 38.5% · Q3 20.8% · Q4 25.9% · 4Q avg 31.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	7.0%	1.6% 5.4 pts worse	1.0% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.7% · Q3 5.0% · Q4 12.1% · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.2%	2.9% 3.3 pts worse	1.7% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 16.0% · Q3 4.5% · Q4 0.0% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.2%	26.6% 3.4 pts better	19.8% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 15.5% · Q3 29.7% · Q4 25.9% · 4Q avg 23.2%
Percentage of long-stay residents with pressure ulcers	0.0%	4.3% 4.3 pts better	5.1% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	72.5%	80.5% 8 pts worse	81.7% 9.2 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 72.5%
Percentage of short-stay residents who had an outpatient emergency department visit	8.7%	11.6% 2.9 pts better	12.0% 3.3 pts better	Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.7% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	42.4%	20.9% 21.5 pts worse	23.9% 18.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 42.4% · Observed 34.8% · Expected 19.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-30 · Fire 2025-07-30

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-07-11 · Fire 2024-07-11

12 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2023-08-09 · Fire 2023-08-09

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-30

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-08-14

E · Potential for more than minimal harm 2024-07-11

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 2024-07-24

E · Potential for more than minimal harm 2024-07-11

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-07-11

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-07-24

E · Potential for more than minimal harm 2023-08-09

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-09-02

E · Potential for more than minimal harm 2023-08-09

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2023-09-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-24

F584 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2025-12-16

F · Potential for more than minimal harm 2025-07-30

F727 · Nursing and Physician Services Deficiencies

Health

Have 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.

Corrected 2025-08-13

F · Potential for more than minimal harm 2025-07-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-08-13

F · Potential for more than minimal harm 2025-07-30

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2025-08-13

E · Potential for more than minimal harm 2025-07-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-13

D · Potential for more than minimal harm 2025-07-30

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-08-13

D · Potential for more than minimal harm 2025-07-30

F688 · Quality of Life and Care Deficiencies

Health

Provide 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.

Corrected 2025-08-13

H · Actual harm 2025-03-25

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 2025-04-09

G · Actual harm 2025-03-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-09

F · Potential for more than minimal harm 2025-03-25

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-04-09

D · Potential for more than minimal harm 2025-03-25

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 2025-04-09

F · Potential for more than minimal harm 2024-07-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-07-11

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-07-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-07-24