Chapters Living: Accident Hazard Safety Failures - IA
The resident, identified in inspection records only as Resident 2, arrived at the facility with what staff documented as incontinence-associated dermatitis on the buttocks. On November 28, 2025, a nurse recorded the wound at 1.42 square centimeters. A physician ordered twice-daily cleansing with soap and water, a barrier cream every shift, and wound evaluations to watch for infection.
One week later, the wound had grown to 19.8 square centimeters, nearly fourteen times its original size.
The December 5 entry was made by the same staff member, identified in records as Staff P, who had documented the wound the week before. There is no record that the dramatic expansion triggered a call to the physician, a care conference, or any change in treatment.
The following week, on December 12, Staff P documented the wound again — this time with no measurements at all.
By December 23, the recorded area had dropped back to 1.4 square centimeters, nearly identical to where it had started. On December 30, a registered nurse identified as Staff J documented the wound at less than 0.1 square centimeters, a sliver smaller than a pencil eraser. A week later, on January 6, Staff P recorded the area at 15.65 square centimeters.
The numbers, taken together, describe a wound that was simultaneously healing and not healing, shrinking to almost nothing and then expanding again to the size of a large postage stamp, all within the span of days. What they actually describe is a monthslong failure of consistent assessment.
The January 6 entry included a photograph. When inspectors reviewed that photo, they found something the written documentation did not mention: two areas of stage 2 pressure ulcers visible on the sacrum and coccyx. Staff P had taken the picture and filed it in the electronic health record. Neither wound appeared anywhere in the written assessment entered the same day.
Stage 2 pressure ulcers involve partial-thickness skin loss. They are not subtle findings.
It was not until January 15, 2026, that a wound evaluation entry finally documented a stage 2 pressure ulcer on the sacrum, described as in-house acquired. That same day, a physician ordered wound cleanser, foam dressings changed every three days, and continued infection monitoring. The orders came more than six weeks after the wound had first ballooned in size, and more than a week after photographic evidence of open ulcers sat unaddressed in the resident's chart.
Inspectors conducting the complaint survey on January 30 reviewed the full sequence of entries. The wound that had been described in November as incontinence-associated dermatitis present on admission had, by mid-January, become a facility-acquired stage 2 pressure ulcer requiring a formal wound care protocol. The documentation trail showed a wound evaluation system that produced numbers without producing understanding, and a photograph that captured what the written record refused to say.
CMS assigned the deficiency a harm level of immediate jeopardy, its most serious designation, meaning the failures created the likelihood of serious injury, harm, or death if not corrected.
The inspection report does not describe what condition Resident 2 was in when surveyors arrived, or what the wound looked like on January 30. It does not say whether the resident experienced pain during the weeks their sacrum was breaking down. It records only what staff wrote, what staff photographed, and what staff chose not to document, leaving a gap between the image in the chart and the words beside it that no plan of correction can fully close.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chapters Living of Council Bluffs from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Chapters Living of Council Bluffs in Council Bluffs, IA was cited for violations during a health inspection on January 30, 2026.
On November 28, 2025, a nurse recorded the wound at 1.42 square centimeters.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.