Chapters Living Of Council Bluffs
Chapters Living of Council Bluffs in Council Bluffs, IA — inspection on January 30, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on resident interviews, staff interviews, facility document review and policy review the facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that is understandable to them.
The facility had a census of 28.Findings include:On 1/27/26 at 10:25 AM during the Resident Council meeting, the residents present indicated they were unaware of having rights, knowing what the Resident Rights were or if they were posted within the facility for their knowledge.Review of Resident Council Minutes for 11/25, 12/25 and 1/26 revealed a variety of facility leadership in attendance at the meetings with no education provided to the residents on Resident Rights.
During the Resident Council meeting on 1/27/26 Staff K, Life Enrichment Director, stated she normally assisted with leading the Resident Council, but if she was not available an Activity Coordinator filled her position.
Staff K acknowledged the staff had not been reviewing/educating residents on Resident Rights during Resident Council meetings.
The Director of Nursing, DON, during the Resident Council meeting on 1/27/26 stated the residents were provided the Resident Rights as part of their admission packets, but concurred the Resident Rights needed to be reviewed with the residents on an ongoing basis.
Neither Staff K nor the DON could confirm the Resident Rights were posted and readily available for the residents.
The facility's Resident Rights Policy, undated, revealed the residents had the right to be supported by the facility in exercising their rights, be informed about their rights and the resident rights were to be posted throughout the facility.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Chapters Living of Council Bluffs
3000 Risen Son Blvd Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #29's document dated 1/12/26 titled, Hospital Progress Notes documented Resident #29 was concerned about returning to the facility because she did not get repositioned.
Document explained Resident #29 acknowledged she had never had an ulcer ever before entering the facility in November.
Discharge plan for return to facility repositioning every 2 hours and placement of wound vacuum.
Review of Resident #29's document dated 1/6/26 at 5:06 PM titled, Operative Report documented Resident #29 had a known sacral decubitus pressure ulcer for the last 2 months, who presented to the hospital with fevers and concern for sepsis from her sacral decubitus wound.
She has undergone some minimal debridement of this in the wound care clinic already.
Her wound had a foul smell and significant necrotic tissue, warranting urgent debridement in the operating room.
Debridement of all of the nonviable completely necrotic tissue which had a foul odor.
The base of the wound was down onto the ligamentous structures running along the posterior sacrum and there was exposed bone. A bone biopsy which was sent separately.
Area was debrided, removal of the necrotic soft tissue down to the bone centrally, and then to the bilateral gluteal muscles.
The total debrided area was 6 cm x 5.5 cm.
Review of Resident #29's EHR titled, Care Plan documented a focus for potential for pressure injury development related to assist needed initiated on 11/11/25 with a in house stage 2 pressure ulcer on sacrum initiated 11/28/25. No new interventions in place for in-house acquired a stage 2 pressure ulcer that was found from 11/28/25.
The care plan does not reflect any new interventions since returning from the hospital with a surgically debrided stage 4 pressure ulcer that requires a wound vacuum.
- The MDS dated [DATE] documented Resident #30 had a BIMS of 13 indicating no cognitive impairment.
The MDS documented Resident #30 was at risk for development of pressure ulcers.
The MDS documented no pressure ulcers.
The MDS documented Resident #30 had an admission date of 12/2/25.
Review of Resident #30 EHR titled, Care Plan documented no care plan update or intervention with unstageable skin found 12/23/25.
On 1/26/26 at 11:35 AM Staff H, MDS Coordinator stated she was familiar with Resident #30.
Staff H acknowledged there was no care plan update with unstageable skin found 12/23/25 and would have updated interventions as well.
On 1/26/26 2:43 PM Staff J, RN stated he does not update care plans.
Staff J stated Staff H, updated care plans.
Staff J stated he does not think floor nurses updated the care plans or develop the interventions on the care plans.
On 1/27/26 at 11:03 AM the DON stated there should be non-pharmaceutical interventions in place right away with any pressure ulcers like off loading and those interventions should be on the residents care plan.
The DON explained Staff H builds the baseline care plan.
The DON stated Staff H completed all the care plan updates.
The DON stated a charge nurse sh
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Chapters Living of Council Bluffs
3000 Risen Son Blvd Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #30's EHR titled, Care Plan documented an intervention / task for oral care dated 12/3/25 that Resident #30 required an assistance of one for oral care.
Review of Resident #30's EHR documented no documentation of oral care provided.
On 1/20/26 at 1:05 PM Resident #30's daughter stated frequently she would come to the facility at random times and would have food on her mother's face and mouth. Resident #30's daughter stated it looked as though her mother's teeth had not been brushed.
On 1/12/26 at 12:49 PM Staff P stated Resident #29 did not want Staff EE or RR in her room because they were talking about their own lives and another resident down the hall.
Staff P stated Resident #29 thought it was disrespectful for them to talk about other residents in her room.
Staff P stated it was an expectation that all residents receive oral care even if the resident does not have teeth.
Staff P stated if the resident had dentures they should be cleaned or soaked overnight.
On 1/12/26 on 1:09 PM the DON stated oral care should be completed or offered and documented if refused.
The DON explained assistance the resident required should be on their care plan as well.
On 1/21/26 at 8:11 AM Staff R, CNA stated if the resident is cognitive she would ask if the resident wanted their teeth brushed before or after the meal.
Staff R stated if the resident was not cognitively aware she would complete the oral cares before breakfast.
Staff R stated she frequently found residents with food on residents faces and hands not cleaned from dinner.
Staff R stated she had brought it up to the management at the facility.
On 1/27/26 at 11:03 AM the DON stated oral care should be completed twice a day ideally by CNA or the nurses if the CNA's are too busy.
Review of undated policy titled, Oral Care documented the purposes of the procedure was to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection.
Review the resident's care plan to assess any special needs of the resident.
Assemble the equipment and supplies as needed.
The following information should be recorded in the resident's medical record: The date and time the mouth care was provided.
The name and title of the individual(s) who provided the mouth care.
All assessment data obtained concerning the resident's mouth.
The certified nursing assistant should report to the licensed nurse to record in the medical record.
Complaints of pain or discomfort of mouth.
The certified nursing assistant should report to the licensed nurse to record in the medical record. If the resident refused the treatment, the reason(s) why and the intervention taken.
The signature and title of the person recording the data.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Chapters Living of Council Bluffs
3000 Risen Son Blvd Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
had completed an investigation and determined the injury was no longer of unknown origins.
The DON stated that Resident #30 had a red area on the right side of her forehead at approximately 7:30 AM on 1/4/26.
The DON explained Staff M notified her, an assessment was completed, and the physician was notified.
The DON stated she asked Staff M if Resident #30 was on a blood thinner and Staff M told her no.
The DON explained she would have only started neuro assessments if the resident was on a blood thinner and had an injury to the head of unknown origins or a change in cognition.
The DON explained a neuro assessment was also completed.
The DON stated Resident #30's daughter was notified.
The DON stated Resident #30's daughter had come to the facility later in the afternoon and asked about the area on Resident #30 forehead as it was now a raised area.
The DON stated Resident #30's daughter must have forgotten about the earlier notification.
The DON stated the raised area was only there for about a day and had decreased and was almost gone the next day.
The DON stated there was no other injuries to Resident #30 from the incident.
The DON stated she completed an investigation and interviewed the staff.
The DON explained the staff had stated Resident #30 did have a shower the day prior but had not fallen.
The DON stated Resident #30 was aggressive and combative the night prior.
The DON explained Resident #30 had kicked an employee in the groin and hit an employee.
The DON stated Resident #30 stated she had hit her head on the bedside table on the morning of 1/4/26.
The DON stated Resident #30's cognition was enough that she felt that is where the injury had come from.
The DON explained the injury probably occurred from the aggression and combativeness of the evening before.
The DON explained the staff had not notified the physician or family appropriately and some writes came from that incident.
The DON stated she would have expected the staff would have notified the DON at 7:30 AM on the day the injury was found when the injury was found and the staff did not.
The DON stated she expected the nurse would have notified the physician of the area on the head at 7:30 AM when it was found as well and that was not completed.
The DON stated she would have expected the family of Resident #30 would have been notified of the injury as well at 7:30 when the injury was noticed.
The DON stated neuro assessments should have been initiated when the area was found on Resident #30 forehead at 7:30 AM and the neuro assessments were not imitated.
Review of Resident #30's EHR dated 1/4/26 titled, Neurological Assessment Flow Sheet documented neurological assessments were not started at 6:00 PM on 1/4/26.Review of Resident #30's EHR dated 1/4/26 at 7:49 PM titled, Skilled Note entered by Staff M documented Resident #30 had a hematoma to the right side of the forehead. On call provider made aware, DON made aware, Resident #30's daughter in and aware.Review of Resident #30's document dated 1/4/26 at 7:27 PM titled Fax documented physician notification that Resident #30 had a 3 cm x 2.5 cm hematoma to the right forehead of unknown origin. On 1/4/26 evening propranolol was held due to blood pressure 102/50 and pulse of 53.
Called to inform the on call provider with no return call at this time.On 1/13/25 at 11:29 AM the Nurse Practitioner stated she was notified on 1/4/26 of Resident #30's area on her forehead.
The Nurse Practitioner stated the staff reported Resident #30 gave several conflicting stories.
The Nurse Practitioner stated she was not made aware of Resident #30 goose egg after the contusion or bruising anywhere else.
The Nurse Practitioner stated she would expect staff to call with any head injuries and start neuro assessments immediately.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Chapters Living of Council Bluffs
3000 Risen Son Blvd Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #2's EHR documented the following:
On 11/28/25 at 2:50 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis that was present on admission on the buttocks that had an area of 1.42 cm2, length of 3.42 cm, and width of 0.61 cm.
On 12/5/25 at 8:03 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis that was present on admission on the buttocks that had an area of 19.8 cm2, length of 8.86 cm, and width of 5.66 cm.
On 12/12/25 at 8:29 AM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that did not have any measurements with the assessment.
On 12/23/25 at 10:14 AM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of 1.4 cm2, length of 2.57 cm, and width of 1.29 cm.
On 12/30/25 at 6:48 AM entered by Staff J, RN titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of <0.1 cm2, length of 0.25 cm, and width of 0.21 cm.
On 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation incontinence associated dermatitis on the buttocks that was present on admission that had an area of 15.65 cm2, length of 7.01 cm, and width of 3.06 cm.
Observation of the photo on EHR dated 1/6/26 at 7:21 PM entered by Staff P titled, Wound Evaluation revealed 2 areas of stage 2 present on sacrum / coccyx area at that time that were undocumented.
Review of Resident #2's EHR dated 1/15/26 at 10:18 AM entered by Staff J titled, Wound Evaluation documented Stage 2 pressure ulcer on the sacrum that was in-house acquired that h
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Chapters Living of Council Bluffs
3000 Risen Son Blvd Council Bluffs, IA 51503
SUMMARY STATEMENT OF DEFICIENCIES
of appropriate water temperature for the facility high or low.
On 1/29/26 at 10:27 AM the DON said 124 degrees for resident room water temperatures was a little too hot.
The DON explained she was not sure what the temperature should be to prevent burns or the timeframe as to when a burn would occur.
On 1/28/26 at 2:56 PM the Administrator stated he was not a temperature expert and could not speak to the appropriate temperature of water for the shower or resident rooms off the top of his head.
The Administrator stated it would be good if Staff Z was trained in the appropriate water temperatures for resident use but was not sure if Staff Z had ever been trained in the appropriate water temperatures for resident use.
No policies presented for appropriate water temperatures for resident rooms and shower rooms, full body mechanical lift use or transportation of residents in wheelchairs.
Facility ID: