Chapters Living of Council Bluffs

In the surveyor’s words

From the most serious findings on record at Chapters Living of Council Bluffs, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jan 30, 2026

  Based on clinical record review, observations, provider interviews, resident interviews, staff interviews, family interviews and policy review the facility failed to ensure staff provided skin assessments, failed to notify the provider of deterioration timely and failed to implement interventions to prevent and treat the development and worsening of pressure ulcers for 7 of 8 residents reviewed (Resident #29, #2, #9, #30, #22, #23, and #21). The facility failure to assess a Stage II pressure ulcer from 12/16/25 through 1/3/26 resulted in Resident #29's wound to deteriorate to an unstageable ulcer due to necrosis (dead tissue) with infection that required debridement of the wound and then hospitalization. […]

• Immediate jeopardy, isolatedF689Jan 26, 2023

  Based on observations, clinical and facility record review, and staff and Climatologist interviews, the facility failed to provide adequate nursing supervision and assistive devices to mitigate a resident's risk for elopement (when a cognitively impaired resident leaves the facility without staff awareness or permission) for 1 of 2 residents reviewed (Resident #2). On 12/1/22, sometime between 1:30 and 1:40 PM, Resident #2 exited the building wearing a long sleeve shirt, long pants, and gripper socks (no shoes). The resident demonstrated severe cognitive impairment with a history of wandering and prior elopement attempts. Staff reported the exit doors did not alarm and they were not aware Resident #2 had left the building until a staff member observed the resident standing outside an exit. […]

• Actual harm, isolatedF684Nov 2, 2022

  I. Based on documents review and interviews, the facility did not monitor and assess the deteriorating health condition to include analysis and evaluation of pertinent factors (low trending intakes and low outputs, diuretic therapy, and the progressive decline in level of consciousness) in order to implement timely measures to alleviate or prevent the illness from getting worse for 1 of 4 residents (Resident # 28) in the sample reviewed for hospitalization . The facility reported a census of 47 residents at the time of the survey. Findings include: Resident # 28's Minimum Data Set (MDS) assessment for significant change in status dated 9/9/22, showed impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4. […]

• Actual harm, isolatedF689Nov 2, 2022

  Based on documents review, interviews, and observation, the facility failed to ensure development and implementation of interventions based on corresponding assessment data in order to prevent fall incidents, and minimize complications resulting from falls for 3 of 5 (#2, #9, #12) residents reviewed for accidents. The facility reported a census of 47 residents at the time of the survey. Findings include: 1. Resident # 3's electronic medical records showed an admitted [DATE] after hospitalization related to right femur fracture. The records also showed that Resident # 3 had 2 incidents of fall since admission, as follows: Fall on 4/15/22 at 1:15 PM. […]

• Actual harm, isolatedF686Jun 23, 2022

  Based on observations, clinical record review, family interviews, provider interviews and staff interviews the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents reviewed (Resident #2, 10 and 11). The facility reported a census of 59 residents. […]