Federal inspectors found gaps in catheter documentation spanning September, October and November 2025, despite physician orders requiring output measurements every shift. Three residents were affected by the documentation failures.
For Resident #3, inspectors discovered a physician's order dated August 7, 2025, requiring catheter output documentation every shift. Yet the facility's Treatment Administration Record showed no documentation for multiple dates in October, including October 4, 14, 17, 30 and 31.
The pattern continued into November. On November 2 and 3, 2025, the overnight shift from 10 p.m. to 6 a.m. showed "no documentation" for catheter output. Electronic medical records contained no explanations for the missing entries.
Staff interviews revealed the significance of the blank records.
Licensed Practical Nurse Staff A told inspectors on November 10 that missing documentation on medication administration records meant "the task was not completed." Another LPN, Staff B, said two days later that when treatments weren't documented, "she would assume it had not been completed."
Registered Nurse Staff C explained the facility's electronic system turned undocumented treatments red during shifts until staff completed the records. The visual reminder system appeared to have failed for catheter monitoring.
The documentation gaps extended across multiple months. Inspectors found the facility "failed to document catheter output for the months of September, October and November 2025."
Facility leadership acknowledged the problems during the November 12 inspection. The Interim Director of Nursing said she expected catheter output recording every shift per physician orders. The Administrator stated that if staff couldn't complete ordered treatments, they should notify the physician and request order modifications if necessary.
The Administrator emphasized expectations for complete documentation, saying he expected "supporting documentation to be made to support the MAR when necessary."
The facility's own Catheter Care, Urinary Policy outlined specific requirements that weren't being met. The policy required emptying collection bags at least every eight hours and following facility procedures for measuring and documenting input and output.
The policy also mandated reporting unusual findings to physicians, including changes in urine appearance and signs of urinary tract infections. Documentation requirements included recording the names and titles of caregivers providing care, along with urine characteristics including color, clarity and odor.
These detailed requirements made the documentation failures more significant. Without proper monitoring records, staff couldn't track changes in residents' conditions or identify potential complications.
Catheter care requires consistent monitoring because residents with urinary catheters face increased risks of infection and other complications. The devices require regular assessment to ensure proper function and early detection of problems.
The inspection revealed systemic documentation problems rather than isolated incidents. Three residents were affected, and the gaps spanned multiple months across different shifts and staff members.
The facility's electronic system included built-in safeguards, with treatments showing in red until documented. Despite these technological prompts, staff consistently left catheter monitoring undocumented.
The November 2025 inspection was conducted in response to complaints, suggesting the documentation problems may have prompted outside concerns about care quality.
Federal regulators classified the violation as causing "minimal harm or potential for actual harm" affecting "some" residents. However, the admission by multiple staff members that blank records indicated incomplete care raised questions about the actual level of monitoring provided.
The facility operates under CMS provider identification number 165466. Inspectors completed their review on November 12, 2025, documenting the catheter care failures as part of a broader compliance assessment.
For residents requiring catheter monitoring, the documentation gaps meant months without verified output tracking. The facility's own staff confirmed that missing records typically indicated missing care, leaving questions about whether residents received the physician-ordered monitoring they needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chapters Living of Council Bluffs from 2025-11-12 including all violations, facility responses, and corrective action plans.
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