Chimney Rock Villa
106 East 13th Street, Bayard, NE 69334 · Morrill County · 49 certified beds · avg 32 residents/day · certified since Jun 1, 2004
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 5, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 25, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 9, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 25, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 9, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 5, 2024 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 24, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jul 30, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Jul 30, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 30, 2025 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Jul 30, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 30, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 25, 2025 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 25, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 25, 2025 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Mar 25, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 11, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 9, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 9, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 5, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 5, 2024 | ▲ G · Actual harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Aug 9, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 9, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 14 | 2 | J ▲ |
| 2025 | 11 | 2 | H ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $110,988.
| Date | Type | Amount / length |
|---|---|---|
| Mar 25, 2025 | Fine | $31,135 |
| Feb 5, 2024 | Fine | $79,853 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.94 | 4.33 | 3.95 | bottom 37% in Nebraska; top 42% in the U.S. |
| Registered Nurse hours | 0.94 | 0.72 | 0.69 | top 21% in Nebraska; top 19% in the U.S. |
| Weekend total nurse staffing | 3.69 | 3.79 | 3.50 | bottom 49% in Nebraska; top 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.59 | 0.47 | 0.48 | top 24% in Nebraska; top 24% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 48.7 | 45.8 | bottom 45% in Nebraska; bottom 38% in the U.S. |
| RN turnover (%) | 42.9 | 44.1 | 42.9 | top 48% in Nebraska; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.47, RN 0.83, weekend 3.25. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 3/5
Who owns this facility
Government - City
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| City of Bayard | Organization | Direct Ownership Interest | NOT APPLICABLE | 05/01/1972 |
| Baird, Chris | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/13/2022 |
| Baird, Chris | Individual | ADP of the SNF | NOT APPLICABLE | 12/13/2022 |
| City of Bayard | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/1972 |
| Clause, Samantha | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/05/2021 |
| Clause, Samantha | Individual | ADP of the SNF | NOT APPLICABLE | 12/05/2021 |
| Henkel, Tanner | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2023 |
| Henkel, Tanner | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Hernandez, Jamie | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/10/2018 |
| Hernandez, Jamie | Individual | ADP of the SNF | NOT APPLICABLE | 12/10/2018 |
| Johnson, Karen | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/18/2019 |
| Johnson, Karen | Individual | ADP of the SNF | NOT APPLICABLE | 02/18/2019 |
| Kienzle, Valerie | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/05/1995 |
| Kienzle, Valerie | Individual | ADP of the SNF | NOT APPLICABLE | 07/05/1995 |
| Kildow, Jeff | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/20/2015 |
| Kildow, Jeff | Individual | ADP of the SNF | NOT APPLICABLE | 08/20/2015 |
| Kraus, Judith | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/08/2020 |
| Kraus, Judith | Individual | ADP of the SNF | NOT APPLICABLE | 12/08/2020 |
| Marquez, Martin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/14/2017 |
| Marquez, Martin | Individual | ADP of the SNF | NOT APPLICABLE | 11/14/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who is your infection preventionist, and what training do they have?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cascades at Skyview | 13.1 mi | Bridgeport, NE | ★☆☆☆☆ | 1/5 | abuseSFF |
| Northfield Retirement Communities Care Center | 18.5 mi | Scottsbluff, NE | ★☆☆☆☆ | 1/5 | |
| Heritage Estates | 18.9 mi | Gering, NE | ★★★★☆ | 3/5 | |
| Monument Healthcare and Nursing Center | 19.3 mi | Scottsbluff, NE | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 285260.