Chapters Living: Rights Notice Failures - IA
The case was rated immediate jeopardy, the most serious level of harm under federal nursing home oversight, meaning inspectors concluded the failures put residents at risk of serious injury or death.
The resident, identified in inspection records only as Resident 2, arrived at the facility with a small wound on the buttocks. On November 28, 2025, staff measured it at 1.42 square centimeters, roughly the size of a fingernail. Seven days later, on December 5, the same staff member documented the wound had expanded to 19.8 square centimeters, an area nearly fourteen times larger. No explanation for the sudden growth appeared in the records inspectors reviewed, and no new physician orders were documented in response to it.
Then the measurements stopped making sense. On December 12, staff conducted a wound evaluation and recorded no measurements at all. On December 23, the wound appeared to have shrunk back to 1.4 square centimeters. By December 30, a registered nurse documented it at less than one-tenth of a square centimeter, essentially gone. A week later, on January 6, the same staff member who had tracked the wound all along documented it again at 15.65 square centimeters, larger than it had ever been measured.
That January 6 entry included a photograph. When inspectors reviewed the photo, they found two distinct stage 2 pressure ulcers visible on the sacrum and coccyx area. Neither had been documented in the wound evaluation entered that day.
A stage 2 pressure ulcer involves partial thickness loss of skin. It is not a subtle finding.
It was not until January 15 that a registered nurse documented a stage 2 pressure ulcer on the sacrum, noting it was acquired inside the facility. That entry, ten days after the photograph showed two wounds that went unrecorded, was the first time a pressure ulcer diagnosis appeared in Resident 2's chart. Physician orders dated January 15 directed staff to cleanse the sacral wound with wound cleanser, apply a foam dressing, and change it every three days. A separate order required evaluation for infection at each assessment.
The physician had also issued orders back on November 28, the day of admission, directing staff to cleanse the buttocks with soap and water, pat dry, and apply a barrier cream every shift until healed. Whether those orders were consistently followed is not detailed in the inspection narrative. What the records do show is that a wound present on admission was still being actively treated nearly two months later, had ballooned and shrunk and ballooned again in the documented measurements, and had been accompanied by at least two additional wounds that staff captured on camera and then left out of the clinical record entirely.
The facility is located at 3000 Risen Son Boulevard in Council Bluffs. The inspection was conducted in response to a complaint.
Wound documentation failures of this kind carry consequences that extend beyond paperwork. When a wound's size is not consistently measured, clinicians cannot track whether a treatment is working or failing. When new wounds appear in a photograph and are not entered into the record, the care team has no way to order treatment, adjust positioning schedules, or notify a physician. The resident continues to be evaluated against a chart that does not reflect their actual condition.
Resident 2's sacral wound, the one that appeared in the January 6 photograph and went undocumented for ten days, was in-house acquired, meaning the facility bore responsibility for its development. How long it had been developing before a staff member's camera captured it, and how long it might have remained undiagnosed without that photograph, the inspection records do not say.
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 4, 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 resident, identified in inspection records only as Resident 2, arrived at the facility with a small wound on the buttocks.
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.