Chapters Living: Immediate Jeopardy Pressure Ulcer Care - IA
That designation matters. It tells the facility, the physician, and any outside reviewer that the wound arrived with the resident, that the home bears no responsibility for it, that it is someone else's problem. At Chapters Living of Council Bluffs, inspectors found that staff applied that label to a wound that was visibly worsening under their care, and that two separate pressure ulcers on the same resident's sacrum went unrecorded for weeks while the documentation described something else entirely.
The resident, identified in inspection records only as Resident #2, had a wound on the buttocks first evaluated on November 28, 2025. At that point it measured 1.42 square centimeters, roughly the size of a small fingernail. A physician ordered cleansing every shift and monitoring for signs of infection.
One week later, on December 5, the same staff member documented the wound again. It had grown to 19.8 square centimeters, more than eight centimeters long. The entry still described it as incontinence associated dermatitis present on admission.
The wound did not hold that size. By December 23, measurements had dropped back to 1.4 square centimeters. On December 30, a registered nurse documented it at less than a tenth of a square centimeter, less than a quarter-centimeter across in either direction. Then, on January 6, 2026, it was back to 15.65 square centimeters.
That January 6 entry is where inspectors found something the documentation had not acknowledged at all. A photo attached to the wound evaluation, entered that evening, showed two areas of stage 2 pressure damage on the sacrum and coccyx. Neither was documented in the written note. Neither had been documented anywhere in the weeks before.
A stage 2 pressure ulcer is not a surface irritation. It involves partial thickness loss of skin, an open wound or blister that has broken through the outer layer into the tissue beneath. The difference between incontinence associated dermatitis and a stage 2 pressure ulcer is the difference between skin that has been irritated by moisture and skin that has been destroyed by sustained pressure. Clinically, they can look similar in early stages. Documenting one as the other, repeatedly, over weeks, means the treatment ordered is for the wrong condition.
It was not until January 15, 2026, that a registered nurse documented a stage 2 pressure ulcer on the sacrum as in-house acquired, meaning the facility acknowledged it had developed on their watch. That entry came 48 days after the wound was first evaluated. A physician order placed the same day called for wound cleanser, a foam dressing, and changes every three days.
Inspectors rated the violation as immediate jeopardy, the most serious classification available under federal nursing home oversight. It indicates that the deficiency caused, or was likely to cause, serious injury, harm, impairment, or death.
The inspection was conducted January 30, 2026, in response to a complaint.
What the records show, laid end to end, is a wound that swelled and shrank and swelled again over nearly two months while staff consistently entered language that pointed away from facility responsibility. The photo taken on January 6 showed open wounds on the sacrum that the written note did not mention. The stage 2 designation did not appear in the chart for another nine days.
Resident #2 spent those weeks with physician orders written for a skin condition that had, by the photographic evidence in their own chart, already become something worse.
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 immediate jeopardy violations during a health inspection on January 30, 2026.
The resident, identified in inspection records only as Resident #2, had a wound on the buttocks first evaluated on November 28, 2025.
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.