Chapters Living Of Council Bluffs

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

occasionally refusing medications, but it was unlike the resident to refuse medications for multiple shifts.

Staff B stated she was not aware of the PCP being notified of the refusals and she had notified the PCP of

the refusals. The staff stated if the MAR had blanks present she would think the medications had not been provided. The staff further revealed the nurse's MAR remained red if medication/treatment had not been provided during that shift providing the nurse with a reminder to complete the medication pass or treatment.

On 11/12/25 at 1:35 PM the Interim Director of Nursing ([NAME]) stated the MAR should contain some sort of documentation as to whether the medication had been provided. The staff stated if a medication order has parameters the medication should never be provided. The IDON stated if there were parameters for a medication the parameters must be entered prior to the administration of the medication. The staff stated if

a medication does not have parameters a nurse might hold a medication until contact is made with the physician to obtain an order to hold the medication. The staff stated if a medication typically has parameters (HTN medications) those were determined by the prescribing physician. The IDON acknowledged the PCP should be notified of resident refusal of medications. The staff stated the facility will attempt 3 times before indicating refusal and will call families with some residents to assist with medication administration and then notify the physician of refusals. On 11/12/25 at 1:55 PM the Administrator stated he did not believe there would be a reason for lack of documentation on the MAR. The Administrator stated medications should not be provided outside of the prescribed parameters or holding a medication without parameters without a physician's approval. The Administrator stated that the PCP should be notified of a resident's refusal of medication(s) and would prefer a note in the Progress Notes with the details of the refusal. The facility's Documentation of Medication Administration Policy revealed a nurse or Certified Medication Aide (CMA) documents all medications administered on the MAR immediately after it is given and reason(s) why a medication was withheld, not administered or refused. The facility's Change in a Resident's Condition or Status Policy revealed the nurse will notify the attending physician or physician on call of a refusal of treatment or medications 2 or more consecutive times and significant change in the resident's physical/emotional/mental condition.The facility did not have a specific policy for following physician orders.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chapters Living of Council Bluffs

3000 Risen Son Blvd Council Bluffs, IA 51503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

documentation for lack of documentation on 10/4, 10/14, 10/17, 10/30 and 10/31/25. Resident #3's 11/25 TAR revealed an order for a urinary catheter: output every shift with an order date 8/7/25. The document contained the following documentation: 11/2/25 10p-6a no documentation11/3/25 10p-6a no documentationThe EMR Progress Notes contained no supporting documentation for lack of documentation for lack of documentation on 11/2 and 11/3/25.The facility failed to document catheter output for the months of September, October and November 2025.On 11/10/25 at 4:15 PM Staff A, Licensed Practical Nurse (LPN) stated if the MAR lacked documentation that meant the task was not completed.On 11/12/25 at 9:35 AM Staff B, LPN, stated if there was no documentation on the MAR for a treatment she would assume it had not been completed.On 11/12/25 at 9:50 AM Staff C, Registered Nurse (RN), stated if treatments were not completed it would be blank on the MAR. The staff further stated the treatment would be shown in red

during the shift until documentation was completed. On 11/12/25 at 1:35 PM the Interim Director of Nursing (IDON) stated she expected that catheter output would be recorded each shift as per physician orders.On 11/12/25 at 1:55 PM the Administrator stated if an order for catheter output was on the order sheet he expected it to be completed and if the facility was unable to complete the order as written then notification needed to be made to the physician and the order changed if necessary. The Administrator expected supporting documentation to be made to support the MAR when necessary.The facility's Catheter Care, Urinary Policy, disclosed the collection bag should be emptied at least every 8 hours and follow the facility's procedure for measuring and documenting input and output. The document further revealed to report unusual findings to the physician including unusual appearance and signs/symptoms of UTI. The document provided documentation in the medical record should include the name and title of the individual(s) providing the care and characteristics of the urine including color, clarity, and odor.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chapters Living of Council Bluffs

3000 Risen Son Blvd Council Bluffs, IA 51503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

related to immobility revised on 7/2/25 contained an intervention of EBP related to catheter and wounds with sign outside the resident's room; gown and gloves used for high contact resident care activities with a face shield used for any tasks that have a high potential for splash or spray revised on 8/15/25.Resident #3's 11/25 TAR revealed an order for EBP related to urinary catheter and wounds with a sign outside the resident's room; gown and gloves used for high contact resident care activities with a face shield used for any tasks that have a high potential for splash or spray with an order date of 8/15/25. The document lacked documentation on 11/3/25 10p-6a.Observation on 11/10/25 at 1:00 PM a U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign posted outside of Resident #3's room with PPE present.Observed on 11/12/25 at 7:50 AM Staff G, CNA, complete hand hygiene, don gown and gloves and obtain a barrier prior to entering the Resident #3's room. The staff completed peri care and catheter care following appropriate infection control techniques. Staff G removed her gloves and donned new gloves without hand hygiene prior to emptying the catheter bag. The Interim Director of Nursing (IDON) was present during the observation.On 11/12/25 the IDON stated EBP should be followed with catheters, pressure ulcers, wounds and incisions. The staff expected PPE to be worn with these individuals when completing direct care tasks with the use of gowns and always wearing gloves. When asked for clarification regarding gloves, the staff stated whenever in the room when not completing tasks gloves should be worn with the example of observing care. The IDON stated hand hygiene should be completed upon entry and exit into a resident's room, incontinence cares and between glove changes. On 11/12/25 the Administrator expected the staff to follow EBP when required. The Administrator expected staff to complete hand hygiene when changing gloves. The facility's EBP Policy revealed EBP is utilized to prevent infection and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. EBP apply to residents with a CDC-targeted MDRO, have a wound or indwelling medical device and contact precautions do not otherwise apply. The document disclosed targeted use of gown and gloves with face protection if there is a risk of splash or spray during tasks including dressing, transferring, hygiene or grooming, device care and wound care. The document revealed staff were trained prior to caring for residents on EBPs. The facility's Handwashing/Hand Hygiene disclosed is the primary means to prevent the spread of healthcare-associated infections. The document revealed hand hygiene is indicated prior to application of non-sterile gloves and immediately after glove removal.The U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign on Resident #2 and Resident #3's doors revealed providers and staff must wear gloves and gown during high contact resident care activities including dressing, bathing, transferring, hygiene, changing briefs or assisting with toileting, device care and wound care.

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