Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
19 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 3
Nov 12, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, catheter care, infection prevention and control, and medication administration in the nursing facility.
Findings
The facility failed to follow physician orders for medication administration, document catheter output, notify physicians of medication refusals, complete catheter care, and implement appropriate infection prevention and control practices including Enhanced Barrier Precautions and hand hygiene. These deficiencies affected multiple residents and posed minimal harm or potential for actual harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide medications as ordered, follow orders for obtaining daily weights, and provided medication outside prescribed parameters for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care, document catheter output, and report changes in eating patterns as signs of UTI for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement appropriate hand hygiene and infection control practices including use of Enhanced Barrier Precautions for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 19
Residents affected: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Primary Care Physician | Named in relation to failure to notify physician of medication refusals for Resident #2 |
| Staff A | Licensed Practical Nurse (LPN) | Provided statements regarding medication administration documentation |
| Staff B | Registered Nurse (RN) | Provided statements regarding medication refusals and documentation |
| Staff E | Certified Nursing Assistant (CNA) | Observed failing to follow Enhanced Barrier Precautions during resident care |
| Staff F | Certified Nursing Assistant (CNA) | Observed failing to follow Enhanced Barrier Precautions during resident care |
| Staff G | Certified Nursing Assistant (CNA) | Observed performing catheter care with some lapses in hand hygiene |
| Interim Director of Nursing | Provided statements regarding expectations for medication administration and infection control | |
| Administrator | Provided statements regarding expectations for medication administration and infection control |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 11
Jun 13, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding housekeeping cleanliness, staff behavior, abuse reporting, and investigation practices at the facility.
Findings
The facility failed to maintain a clean environment, failed to timely report and thoroughly investigate alleged abuse and neglect, failed to develop and update comprehensive care plans, failed to provide appropriate fall prevention and neurological assessments, failed to ensure treatment orders were signed out as completed, failed to provide sufficient nursing staff, failed to update the facility assessment, and failed to employ a qualified infection preventionist.
Complaint Details
The complaint investigation involved allegations of poor housekeeping, staff rudeness and neglect, failure to report abuse, inadequate investigations, and failure to provide appropriate care and documentation. The facility reported a census of 26 residents. The investigation included resident interviews, staff interviews, record reviews, and policy reviews. Some allegations were substantiated with findings of deficiencies in care and compliance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to maintain a clean environment for residents, including housekeeping not cleaning Resident #4's room and bathroom. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and neglect regarding Resident #3's complaint about staff behavior and call light removal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate allegations of staff being rude and mean to residents, including inadequate resident and staff interviews. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for residents with pressure ulcers, lacking specific type, location, and preventive interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update care plans timely after residents experienced falls and development of new pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate fall prevention interventions and neurological assessments after unwitnessed falls for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure treatment orders for pressure ulcers and wounds were signed out as completed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient nursing staff to meet resident needs and timely assist residents, including use of mechanical lifts with inadequate staffing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct and update a facility-wide assessment to determine necessary resources for competent resident care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a qualified infection preventionist responsible for the infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medical records, including bathing documentation and incident reports. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 26
Resident count reviewed: 10
Pressure ulcers stage 4: 3
BIMS scores: Various residents' cognitive scores ranging from 2 to 15 as documented
Falls documented: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in complaint regarding rude behavior and call light removal from Resident #3's room |
| Director of Nursing | Director of Nursing (DON) | Involved in investigation and education of staff, acknowledged failures in reporting abuse |
| Staff G | Previous Administrator | Informed about Staff F incident, abuse coordinator role, and investigation deficiencies |
| Staff I | Previous Scheduler/Certified Medication Aide (CMA) | Reported Resident #3's concerns about Staff F |
| Staff H | Certified Nursing Assistant (CNA) | Reported issues with Staff F and Resident #3 |
| Staff J | Certified Nursing Assistant (CNA) | Provided care to Resident #4 and reported on behaviors and care |
| Staff K | Licensed Practical Nurse (LPN) | Assisted with Resident #4 care and reported on fall and behaviors |
| Staff L | Certified Nursing Assistant (CNA) | Reported staffing shortages and use of mechanical lifts |
| Staff M | Licensed Practical Nurse (LPN) | Provided information on care plans and neurological assessments |
| Staff N | Certified Nursing Assistant (CNA) | Reported on care plan use and pressure ulcer interventions |
| Staff O | Certified Nursing Assistant (CNA) | Reported on pressure ulcer and fall interventions |
| MDS Coordinator | Minimum Data Set Coordinator/Infection Preventionist | Serves as Infection Preventionist, undergoing training, involved in antibiotic stewardship |
| Skilled Unit Manager | Assistant Director of Nursing (ADON) | Provided information on policies, care plans, and staffing |
| Administrator | Facility Administrator | Provided facility assessment and staffing information |
| CEO | Chief Executive Officer | Provided information on facility assessment updates |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Jan 9, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding dignity and respect during personal care, professional standards of quality in care, discharge planning, pain management, and infection prevention practices at Chapters Living of Council Bluffs.
Findings
The facility failed to provide dignity and respect during personal care to some residents, failed to follow professional standards for blood glucose and blood pressure management, failed to ensure follow-up services before discharge for a resident, failed to assess and manage pain adequately for a resident, and failed to implement proper infection prevention practices including PPE use for residents on precautions.
Complaint Details
The visit was complaint-related, investigating allegations of undignified care by staff, failure to follow professional care standards, inadequate discharge planning, poor pain management, and infection control breaches. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide dignity and respect during personal cares to 2 of 22 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of quality for blood glucose and blood pressure management for 2 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure follow-up services and appointments were established before discharge for 1 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess pain and complete vitals and comprehensive assessment prior to transfer for 1 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate infection prevention practices when providing personal care and catheter care to residents on Enhanced Barrier Precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 3
Census: 22
Blood pressure readings: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurse Assistant (CNA) | Reported undignified care by Staff H and cared for Resident #171 during pain episodes |
| Staff H | Certified Nurse Assistant (CNA) | Alleged to have treated residents without dignity |
| Staff I | Licensed Practical Nurse (LPN) | Received reports about undignified care and involved in pain assessment for Resident #171 |
| Staff J | Registered Nurse (RN)/Nurse Manager | Notified about undignified care incidents and pain management |
| Staff B | Licensed Practical Nurse (LPN)/Infection Preventionist (IP) nurse manager/Staff Development Coordinator | Provided information on reporting chain and infection control expectations |
| Staff C | Certified Medication Aide (CMA) | Discussed blood pressure medication parameters and infection control practices |
| Staff D | Registered Nurse (RN) | Discussed blood pressure medication parameters |
| Staff L | Registered Nurse (RN) | Cared for Resident #180 and discussed infection control practices |
| Staff K | Certified Nurse Assistant (CNA) | Performed catheter care and discussed PPE use |
| Staff M | Licensed Practical Nurse (LPN) | Documented progress notes for Resident #180 |
| Administrator | Provided statements regarding incident reporting, discharge planning, and infection control expectations | |
| Director of Nursing (DON) | Provided statements on incident reporting, pain management, and infection control | |
| Medical Director | Provided parameters for holding hypertension medication | |
| Social Worker (SW) | Discussed discharge planning and follow-up services for Resident #173 |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 7
Jan 9, 2025
Visit Reason
The inspection was conducted to investigate complaints related to dignity and respect during personal care, accuracy of resident assessments, professional standards of care, discharge planning, pain management, infection control during food service, and staff training compliance.
Findings
The facility was found to have multiple deficiencies including failure to provide dignity and respect to residents, inaccurate resident assessments, failure to follow professional standards of care, inadequate discharge planning, failure to properly assess and manage pain, improper infection control practices during food service, and incomplete mandatory reporter training for staff.
Complaint Details
The visit was complaint-related, investigating allegations of undignified treatment by staff, inaccurate resident assessments, failure to follow professional standards, inadequate discharge planning, pain management issues, infection control lapses, and incomplete staff training. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide dignity and respect during personal cares to 2 of 22 residents reviewed (Resident #8 and #175). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of insulin for 1 of 10 residents reviewed (Resident #15). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow professional standards of quality for 2 of 4 residents reviewed related to blood glucose and blood pressure management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that follow up services and appointments were established before discharge for 1 of 3 residents reviewed (Resident #173). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess pain and complete vitals and comprehensive assessment prior to transfer for 1 of 4 residents reviewed (Resident #171). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control measures were used during food service; staff touched several surfaces with gloves before touching food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all staff completed the required Dependent Adult Mandatory Reporter Training for 1 of 5 staff reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurse Assistant (CNA) | Reported undignified treatment of residents and involved in pain management observations |
| Staff I | Licensed Practical Nurse (LPN) | Involved in reporting and assessing dignity complaints and pain management |
| Staff J | Registered Nurse (RN)/Nurse Manager | Involved in management response to dignity complaints |
| Staff D | Registered Nurse (RN)/MDS Coordinator | Provided information on insulin use and MDS accuracy |
| Staff B | Licensed Practical Nurse (LPN)/Infection Preventionist (IP) Nurse Manager/Staff Development Coordinator | Provided information on reporting chain of command and infection control |
| Staff F | Culinary Supervisor (CS) | Observed improperly using gloves during food preparation |
| Staff E | Certified Nurse Aide (CNA) | Had expired Dependent Adult Mandatory Reporter training |
| Administrator | Provided statements regarding dignity complaints, discharge planning, and staff training | |
| Director of Nursing (DON) | Provided statements regarding dignity complaints, pain management, and professional standards | |
| Medical Director | Provided parameters for holding hypertension medication | |
| Social Worker (SW) | Involved in discharge planning and follow-up services for Resident #173 |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 2
Jan 10, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to protect residents from possible abuse, including sexual and physical abuse by Resident #182, and failure to conduct thorough investigations of alleged abuse incidents.
Findings
The facility failed to implement appropriate interventions to protect residents from abuse and did not complete thorough investigations for alleged abuse incidents, lacking witness statements and proper documentation. The facility reported a census of 25 residents and had minimal harm or potential for actual harm with few residents affected.
Complaint Details
The complaint investigation revealed failure to protect 1 female resident from possible sexual abuse and 1 male resident from possible physical abuse by Resident #182. Investigations lacked witness statements and proper documentation for incidents dated 4/29/23 and 5/12/23 involving Residents #183 and #184. The Director of Nursing and Executive Director emphasized expectations for adequate supervision and proper investigations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect residents from all types of abuse including sexual and physical abuse by Resident #182. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete thorough investigations for possible abuse by not interviewing all witnesses for incidents involving Residents #183 and #184. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 25
Incidents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Interviewed regarding Resident #182's behavior and abuse incidents |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding observations of Resident #182 and 1:1 supervision |
| Staff G | Certified Nursing Assistant (CNA) | Interviewed regarding night shift observations of Resident #182 |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed regarding awareness of abuse incidents involving Resident #182 |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for supervision and investigations |
| Executive Director | Executive Director | Interviewed regarding expectations for abuse prevention and investigations |
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing appropriate care to maintain or improve residents' range of motion and mobility, specifically reviewing treatment services for Resident #22.
Findings
The facility failed to provide adequate restorative or therapy services to Resident #22, who had decreased range of motion, due to insurance coverage issues and lack of a formal restorative program. The resident showed progress during prior therapy but was unable to continue therapy because of insurance denial.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate care to maintain and/or improve range of motion (ROM), limited ROM and/or mobility for Resident #22. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 25
Residents reviewed: 12
Gait distance: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided information about Resident #22's therapy and insurance issues | |
| Director of Nursing | Director of Nursing (DON) | Discussed insurance coverage and restorative program status related to Resident #22 |
Inspection Report
Routine
Census: 47
Deficiencies: 11
Nov 2, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Chapters Living of Council Bluffs.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach and answered timely, failure to provide meal choices, inadequate cleanliness, failure to notify bed hold status, incomplete care plans, failure to perform neurological assessments after falls, inadequate pressure ulcer care, insufficient fall prevention interventions, delayed response to call lights, improper medication storage and labeling, and unsafe disposal of sharps.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Actual harm: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to consistently offer means to notify staff of personal needs for 2 of 16 residents; call lights not within reach and not answered timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to allow meal food choices for 2 of 2 residents sampled. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a clean and homelike environment for 1 of 16 residents; trash and debris observed in resident room. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to issue bed hold notification to resident's representative when resident admitted to higher level of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop a comprehensive care plan including specific interventions for diuretic therapy for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform neurological assessments following an unwitnessed fall for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure development and implementation of interventions to prevent falls and minimize complications for 3 residents. | Level of Harm - Actual harm |
| Failure to discard expired medications and ensure proper labeling and separation of clean and dirty supplies in medication rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe environment related to improper disposal of glucometer needles/lancets in trash bins. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond to call lights and resident needs in a timely manner for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store utensils inverted, cover food during transport, and perform hand hygiene when indicated. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Call light wait times exceeding 15 minutes: 106
Facility census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Medication Aide | Interviewed regarding call light response and meal selection |
| Staff I | Certified Nursing Assistant | Interviewed regarding call light response and meal selection |
| Staff J | Licensed Practical Nurse | Interviewed regarding call light response |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding call light expectations, care plans, neurological assessments, and medication disposal |
| Staff L | Physical Therapist | Interviewed regarding therapy and transfer recommendations |
| Staff P | Nurse Manager | Involved in resident transfer during fall incident |
| Staff T | Certified Nursing Assistant | Observed transferring resident without gait belt |
| Staff D | Licensed Practical Nurse | Observed medication room and acknowledged medication labeling importance |
| Staff S | Registered Nurse | Observed improperly disposing glucometer needles |
| Staff G | Certified Nursing Assistant | Interviewed regarding resident fall and brace use |
| Staff E | Certified Nursing Assistant | Interviewed regarding resident fall and brace use |
| Staff F | Physical Therapist Assistant | Interviewed regarding resident brace use |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding resident fall and pain assessment |
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