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Chapters Living: Hand Hygiene Failures During Care - IA
The violation occurred on November 12 at 7:50 AM at Chapters Living of Council Bluffs....
Latest reports, citations, and penalties from CMS data
The violation occurred on November 12 at 7:50 AM at Chapters Living of Council Bluffs....
The incident occurred when Resident #2 was walking down a hallway and encountered Resident #1, who was talking with a nursing assistant....
Resident #6 told federal inspectors that Resident #8 put his hand on her left knee, rubbing and moving upward on her thigh until she pushed him away....
Certified Nursing Assistant 2 discovered Resident 2 kissing Resident 1's lips and laying on top of him in Resident 1's bed....
The error at The Heights of Alamo created a fundamental contradiction in Resident #1's medical instructions....
Federal inspectors determined the incident posed immediate danger to resident health and safety....
Licensed nurse LN 8 administered the resident's medications around 9:30 a.m....
The nursing assistant, identified in inspection records only as CNA 1, brought the resident into the dining room around 3 p.m....
Federal inspectors observed the medication violations during a 10-minute period that morning....
Day shift staff weren't told about the malfunction and had no idea they needed to increase supervision of residents with dementia....
The discovery triggered an immediate response on October 30, including deep cleaning of the affected resident's room and emergency pest control treatment....
The October 8 confrontation began when Resident B was sitting in the back west hallway with a female resident nearby....
The facility's investigation was riddled with missing documentation and contradictory accounts....
The resident, identified only as R1 in inspection records, fell at 5:05 AM on October 28, sustaining the fracture that required medical treatment....
But when she reviewed the resident's file with the surveyor, she found no discharge instructions or summary had been created....
The facility served meals from mobile carts with plastic dome covers but no plate warmers....
The incident occurred at St Annes Nursing Center on October 9, 2025, around 6:00 AM as staff prepared Resident #1 for dialysis....
Federal inspectors found the 112-bed facility displaying nursing staff data from September 11 when they arrived on September 16....
Federal inspectors found that Harmony Dubuque violated residents' rights to communicate with family members during a November complaint investigation....
The October incident left the facility without a roadmap for staff to follow, despite physician orders for daily wound care that would continue for two weeks....