Chimney Rock Villa

In the surveyor’s words

From the most serious findings on record at Chimney Rock Villa, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 5, 2024

  Licensure Reference Number 175 NAC 12-006.09D2a Based on record review and interviews; the facility staff 1) failed to assess residents for skin impairment, existing pressure ulcers (localized injury to the skin and/or underlying tissue over a bony prominence as a result of pressure, or pressure in a combination with shear and/or friction), or new pressure ulcers; 2) failed to implement interventions to treat and prevent the development of pressure ulcers; 3) failed to monitor residents' skin, 4) failed to follow provider orders to promote wound healing for 2 (Residents 2 and 1) of 4 sampled residents. The facility identified a facility census of 31 residents at the time of the survey. Findings are: A. […]

• Immediate jeopardy, isolatedF609Jun 22, 2022

  Licensure Reference Number: 175 NAC 12-006.02 and 175 NAC 12-006.05(9) Based on record review and interviews, the facility failed to identify an allegation of staff to resident abuse and failed to put measures in place to protect the resident from further potential abuse for one current sampled resident (Resident 5). The facility census was 39 with 15 current sampled residents. Findings are: Interview with Resident 5 on 6/15/22 at 4:02 PM, revealed on May 21, 2022, NA (Nursing Assistant)-A was performing peri care after the resident had a bowel movement (bm) and had applied pressure on resident's lower abdomen with NA-A's arm/elbow. Resident 5 disclosed that NA-A had placed three fingers and a wipe soiled with feces in Resident 5's vagina. […]

• Actual harm, patternF689Mar 25, 2025

  Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record reviews and interviews, the facility failed to develop and or implement appropriate interventions to prevent additional falls for 4 (Residents 2, 4, 6, and 7), which resulted in two residents (Resident 4 and 7) sustaining major injuries from subsequent falls. The facility identified a census of 24. Findings are: A record review of a facility policy, Assessing Falls and Their Causes, with a revised date of March 2018, revealed when a resident falls, an appropriate intervention taken to prevent future falls should be recorded in the resident's medical records. A. […]

• Actual harm, isolatedF684Mar 25, 2025

  Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on record reviews and interviews, the facility failed to provide ongoing monitoring of an incision, follow physician's orders for care of the incision, and implement treatment and other interventions to promote healing and prevent infection for 1 (Resident 7) of 4 sampled residents. The facility identified a census of 24. Findings are: A record review of a facility policy, Wound Care, with a last revised date of October 2010, revealed the purpose of the policy was to provide guidelines for the care of wounds to promote healing. The policy revealed an assessment of the wound (including color, size, drainage, etc.) should be documented with wound care. […]

• Actual harm, isolatedF867Feb 5, 2024

  Licensure Reference Number 175 NAC 12-006.07C Based on record reviews and interview, the facility failed to identify, monitor, and evaluate a system for pressure ulcers as part of the Quality Assurance and Performance Improvement (QAPI) committee's performance improvement activities. This affected 2 (Residents 1 & 2) of 4 sampled residents. The facility census was 34. The Findings are: A record review of the facility's QA (Quality Assurance) binder on 2/5/24 revealed there were no QAPI meeting minutes for January 2024. […]