Latest reports, citations, and penalties from CMS data
Licensed Vocational Nurse B told inspectors that nursing aides typically performed the weighings and reported results to her for entry into medical records....
Federal inspectors found the facility violated basic notification requirements during the November incident....
The allegations came in an email from the resident's healthcare proxy on September 30, 2025, at 8:08 PM....
The resident submitted their request on August 4, 2025....
The violations covered abuse and neglect protections, mandatory reporting requirements, and the facility's duty to investigate and prevent violations....
An hour later, the administrator delivered what appeared to be the requested files....
The first incident occurred on October 5 when Resident #1 and Resident #4 were found in Resident #1's roommate's bed without pants on....
The October incidents involved a male dementia patient identified as Resident #1 and two female residents....
Resident #1 told inspectors during a November 10 phone interview that their roommate had been taking their clothes, shoes and food for an extended period....
Resident 1, who has multiple sclerosis and no cognitive impairment, had declined authorization for any photographs on January 4, 2023....
The violation occurred on November 12 at 7:50 AM at Chapters Living of Council Bluffs....
When nurses encountered these empty spaces, they assumed medications simply hadn't been given rather than refused by residents....
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....
The October 2nd incident at Monticello Nursing & Rehab Center involved two residents whose confrontation escalated to physical violence....
Three residents were affected by the documentation failures....
Certified Nursing Assistant 2 discovered Resident 2 kissing Resident 1's lips and laying on top of him in Resident 1's bed....
The June 13, 2025 incident involved two residents with severe cognitive impairment, according to federal inspection records....
The Director of Staff Development told federal inspectors in November that she wasn't even notified about the sexual abuse incident....
The error at The Heights of Alamo created a fundamental contradiction in Resident #1's medical instructions....