Chapters Living: Daily Care Assistance Failures - IA
Federal inspectors visiting Chapters Living of Council Bluffs on January 30 found the facility had been mismanaging a deteriorating skin wound on a resident identified in records as Resident 2 since at least late November. The deficiency was cited at immediate jeopardy, the most serious level CMS assigns, meaning inspectors concluded the facility's failures had placed the resident at risk of serious harm or death.
The wound first appeared in the electronic health record on November 28, 2025, when a staff member identified as Staff P documented incontinence-associated dermatitis on the resident's buttocks. The area measured 1.42 square centimeters, roughly the size of a fingernail. A physician's order that same day directed staff to cleanse the area with soap and water every shift and apply a barrier cream until it healed.
One week later, Staff P documented the same wound again. The area had grown to 19.8 square centimeters, an increase of more than 1,300 percent in seven days. The entry still described it as incontinence-associated dermatitis present on admission.
The December 12 entry had no measurements at all.
By December 23, the recorded area had dropped back to 1.4 square centimeters. A week after that, on December 30, a registered nurse identified as Staff J documented the wound at less than a tenth of a square centimeter, essentially healed. The entry again described the condition as present on admission.
Then, on January 6, Staff P documented the wound again. The area was now 15.65 square centimeters, more than seven centimeters long. The entry, once more, described incontinence-associated dermatitis present on admission.
Inspectors reviewed the photograph attached to that January 6 entry. The image showed two separate stage 2 pressure ulcers on the sacrum and coccyx. Neither wound had been documented anywhere in the record. A stage 2 pressure ulcer is not a skin irritation from moisture. It is an open wound, a partial-thickness loss of skin that reaches into the dermis.
Neither wound had a physician's order. Neither had a treatment plan. Neither had, apparently, been identified as a wound at all.
A physician's order for a sacral stage 2 pressure ulcer did not appear in the record until January 15, nine days after the photograph showed two of them. That order directed staff to cleanse the wound with wound cleanser, apply a foam dressing, and change it every three days. A separate order that day directed evaluation for signs of infection. The January 15 entry, entered by Staff J, was the first time the record acknowledged the wound was acquired inside the facility.
The inspection report does not explain the swings in documented wound size, the December entries showing near-complete resolution followed by a January return to 15 square centimeters. It does not say whether the wound was actually improving and then worsened, or whether the measurements were inaccurate, or whether staff were examining a different area of skin on different dates. What the record shows is that on November 28 there was a wound, on January 6 there were two stage 2 pressure ulcers visible in a photograph, and for the weeks in between, every entry in the chart called it a pre-existing condition.
The facility is located at 3000 Risen Son Boulevard. The inspection was completed January 30, 2026.
The resident's name does not appear in the inspection report. What does appear is the photograph from January 6, attached to a chart entry that still described the wound as something the resident had brought through the door.
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.
The area measured 1.42 square centimeters, roughly the size of a fingernail.
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.