Chapters Living of Council Bluffs

Inspectors wroteBased 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. Significant debridement required with the wound base extending down into ligamentous structures running along the posterior sacrum and there was exposed bone. [...]

Inspectors wroteBased on clinical record review, policy review, resident interviews, family interviews, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of each resident and resident representative to allow developing the care plan and making decisions about his or her care. The facility also failed to complete revisions to care plans when there was a change in the residents care to 10 of 20 residents reviewed (Resident #23, #11, #7, #8, #21 #2, #3, #9, #29, and #30). The facility reported a census of 28 residents.

Inspectors wroteBased on the facility assessment, Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 4 2025 ([DATE] - [DATE]) review, facility staffing reports review, policy review and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 28 residents.

Inspectors wroteBased on facility assessment, clinical record review, staff interviews, and facility plan review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies in 11 areas over the last year and development of performance improvement plans (PIPs) for monitoring and tracking for effectiveness. The facility reported a census of 28 residents.

Inspectors wroteBased on facility assessment, clinical record review and staff interview the facility failed to properly establish and implement written policies and procedures for the Quality Assurance and Performance Improvement (QAPI) plan and properly monitor and measure its success and track performance to ensure that improvements are realized and sustained for the QAPI plan. The facility reported a census of 28 residents.

Inspectors wroteBased on document review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 28 residents.

Inspectors wroteBased on staff interviews, facility assessment review and facility policy review the facility failed to develop and implement a facility wide system to monitor protocols and the use of antibiotics prescribed to residents. The facility reported a census of 28 residents.

Inspectors wroteBased on staff interviews, employee record review, and facility policy review, the facility failed to offer COVID 19 vaccinations and education regarding the benefits of vaccination to facility employees. The facility reported a census of 28 residents.

Inspectors wroteBased on Resident Council Meeting, observations, clinical record review, resident interviews, staff interviews and policy review the facility failed to provide dignity and respect. Staff refused to wear gloves, a staff was reported to have gone through a resident's personal belongings, pushing a resident partially exposed in a wheelchair (w/c), residents reporting being spoken to rudely, residents stating care was denied or length of time to provide care, and fear of retaliation from staff to 6 of 12 residents reviewed (Resident #7, #17, #33, #16, #15 and #29 ). The facility reported a census of 28 residents.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, resident interviews, staff interviews, and facility document reviews the facility failed to provide residents and/or their representatives accessible reports related to surveys, certifications and complaint investigations for the facility during the 3 preceding years and any plan of correction with respect to the facility. The facility had a census of 28.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, family interview, provider interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) and physician for change in condition when a resident had a head injury and residents had a new or worsening wound for 4 of 4 residents (Residents #2, #15, #29, #30 and #23) reviewed. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews, and staff interviews the facility failed to provide the residents with a comfortable / clean homelike environment by resident rooms found with various debris on the floor and failed to ensure resident's personal property was protected from loss or theft no personal inventory sheet was completed upon entry to the facility for 4 of 12 residents reviewed (Resident #15, #30, #38 and #11). The facility reported a census of 28 residents.

Inspectors wroteBased on resident council meeting, resident interview, staff interviews, document review and policy review the facility failed to document grievances when residents voiced concerns, educated staff on where grievance forms could be found and when to fill grievance forms out, make prompt efforts to resolve grievances the resident may have and have grievance forms available for staff, residents and resident family members to complete for 2 of 2 residents reviewed (Resident #15 and #29). The facility reported a census of 28 residents.

Inspectors wroteBased on personnel file review, staff interviews and policy review the facility failed to perform further background checks clearing an employee for hire that was on probation for exploitation. The facility reported a census of 28 residents.

Inspectors wroteBased on personnel file review, policy review, document review, and staff interviews the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility also failed to implement their abuse policies when staff reported concerns about a staff member and complete further research when Staff A's background check suggested one be completed. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to complete a thorough investigation when it was reported Staff A signed out Resident #3's oxycodone but failed to administer the medication. The facility also failed to investigate concerns brought to them from staff members related to Staff A in September and December. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, record review, staff and family interviews, and facility policy review. The facility failed to provide oral cares for 5 of 5 residents (Resident #22, #2, #3, #29, and #30) reviewed and also failed to provide toileting and repositioning for Resident #29. The facility reported a census of 28 residents.

Inspectors wroteBased on facility document review, Facility Assessment review and staff interviews the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) at all times. The facility reported a census of 28 residents.

Inspectors wroteBased on observation, clinical record review, interviews and policy review the facility failed to protect residents from possible accidents and injuries for 4 of 12 residents (Residents #7, #41, #2 and #3) reviewed. The facility failed to protect residents when dependently pushed in manual wheelchairs (w/c's) without the use of footrests and using only 1 staff member with the use of dependent non-weight bearing mechanical lifts. Additionally the facility failed to protect the residents from possible scalding injuries with water temperatures above the recommended temperature range for burn prevention. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, staff interview and facility policy review the facility failed to provide drinks to residents, during lunch service. The facility reported a census of 28 residents.

Inspectors wroteBased on facility document review, Facility Assessment review and staff interviews the facility failed to provide enough nursing staff to assure residents safety with transfers, provided appropriate care and resident care completed in a timely manner. The facility reported a census of 28.

Inspectors wroteBased on facility document review, Facility Assessment review and staff interviews the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not providing staff orientation for newly hired staff or agency staff. The facility reported a census of 28 residents.

Inspectors wroteBased on facility document review, facility assessment review and staff interviews the facility failed to ensure a Registered Nurse (RN) was at the facility for 8 consecutive hours. The facility reported a census of 28.

Inspectors wroteBased on facility assessment review, facility document review and staff interviews the facility failed to complete an employee performance review at least once every 12 months. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, staff interviews and facility policy review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. Areas identified for failure for employment of nutritional management staff with competencies included food preparation, meal delivery not including licensed nurses, nurse aides or paid feeding assistants involved with assisting residents with eating, meal service delivery in a timely manner to maintain food safety and temperature and within 45 minutes or less of resident request and facility's scheduled time for meals.

Inspectors wroteBased on observation, facility document review, staff interviews, and facility policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs of residents by not following the approved menu for a meal. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews and policy review the facility failed to provide food at an appetizing temperature to 6 of 20 residents reviewed (Resident #17, #42, #36, #44, #3 and #15). The facility reported a census of 28 residents.

Inspectors wroteBased on observations, interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for 3 of 8 residents (Resident #3, #9, #15) reviewed, as well as general practices for mealtime service. The facility reported a census of 28 residents.

Inspectors wroteBased on observations and staff interviews the facility failed to properly dispose of room trays with left-over food and beverages in a timely manner. The facility further failed to dispose of garbage and waste properly. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview, policy review and facility document review the facility failed to provide complete and accurate records when inventory lists were not completed, failed to accurately document administration of medication, documented treatments completed before doing them, failed to lock or close a laptop leaving confidential health information accessible, and documented refrigerator temperatures falsely for 7 of 12 resident reviewed (Resident #3, #15, #11, #44, #21, #3 and #11). The facility reported a census of 28 residents.

Inspectors wroteBased on observations, facility policy review, and staff interviews the facility failed to ensure staff utilized consistent infection controls techniques as evidenced by a failure to complete hand hygiene during resident cares, remove personal protective equipment prior to exiting a residents room, sanitize shared resident equipment after use, and ensure catheter tubing, and oxygen tube secured in a position to not fall on the floor for 6 of 12 residents (Resident's #2, #22, #23, #11, #3 and #17) in the sample, and failed to review the infection control policy at least annually. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, and staff interviews the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS-10055 for 3/3 residents reviewed (Resident #50, #51, #52). The facility reported a census of 28.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy review the facility failed to ensure 3 of 5 residents (Resident #3, 11, and 32) reviewed were free from exploitation. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, document review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 3 residents (Resident #5 and #29) reviewed. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to accurately code the type of assessment for 1 of 2 discharge Minimum Data Set (MDS) assessments (a federally mandated, standardized, comprehensive clinical assessment tool used in nursing homes to evaluate functional, medical, and psychological status, it identifies resident problems, strengths, and preferences to guide care planning and determine reimbursement) (Resident #5). The facility also failed to accurately code medications taken when reviewing unnecessary medications for 2 of 3 residents (Resident #5 and #23). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, interviews, and policy review the facility failed to develop and implement a Baseline Care Plan for 2 of 10 residents (Residents #17, #42) reviewed. The facility failed to develop and involve the resident and/or resident representative in the development of the Baseline Care Plan within 48 hours of admission. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, record review, interviews and policy review the facility failed to provide resident centered activities that incorporated the resident's interests, hobbies to maintain and/or improve a resident's physical, mental and psychosocial well-being and independence for 1/10 residents (Resident #21) reviewed. The facility failed to create opportunities for the resident to have a meaningful life by supporting her domain of wellness (autonomy, connectedness, joy and meaning). The facility reported a census of 28.

Inspectors wroteBased on clinical record review, provider interview, resident and family interview, staff interviews, and policy review the facility failed to appropriately assess a resident with a head injury and appropriately complete assessments / provide interventions for a diabetic ulcer for 2 of 8 residents (Resident #15, and #30). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interviews, and observation the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral flushes with a piston syringe into the enteral tube for 1 of 1 residents (Resident #44). The facility reported a census of 28 residents.

Inspectors wroteBased on observations, electronic medical record (EMR) reviews, resident and staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents (Resident #17) reviewed, requiring the use of oxygen. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy review the facility failed to prepare and serve food in a form designed to meet individual needs and according to their assessments and Care Plans for 3 of 5 residents (Residents #3, #13, #23) reviewed. The facility failed to prepare and serve 3 meals according to the residents' prescribed diet orders. The facility reported a census of 28 residents.

Inspectors wroteBased on observations, clinical record reviews, family and staff interviews and policy review the facility failed to provide therapeutic diets as prescribed by the primary care provider for 3 of 6 residents (Resident #23, #33, #42,) reviewed. The facility failed to follow physician orders for consistent carbohydrate (CCHO) and renal diets. The facility reported a census of 28.

Inspectors wroteBased on record reviews, staff interviews, and policy review the facility failed to provide the needed services in accordance with professional standards by not following physician orders for 3 of 3 residents (Resident #1, #2, #4, #3). The facility reported a census of 19 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 3 of 3 residents reviewed (Resident #1, #2, #3). The facility reported a census of 19 residents.

Inspectors wroteBased on observation, Electronic Health Record (EHR) reviews, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares for 2 of 3 residents (Resident #2, #3). The facility failed to utilize Enhanced Barrier Precautions (EBP) and complete hand hygiene. The facility reported a census of 19.

Inspectors wroteBased on observations, record review, resident and staff interview, and facility policy review the facility failed to provide the appropriate interventions to prevent falls for 2 or 3 residents (Resident #1, #9, and #10). The facility also failed to complete neurological assessments after 2 of 4 residents (Resident #4 and #10) after they experienced an unwitnessed fall. The facility reported a census of 26 residents.

Inspectors wroteBased on review of the facility's assessment and staff interview the facility failed to update the Facility Assessment. The facility reported a census of 26 residents.

Inspectors wroteBased on document reviews, staff interviews, and policy review the facility failed to employ a qualified person to serve as the Infection Preventionist (IP) for the facility. The facility reported a census of 26 residents.

Inspectors wroteBased on observations, family and staff interviews, the facility failed to maintain a clean environment for residents. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, facility investigative file review, staff and family interviews the facility failed to report to the State Agency, when Resident #3 reported staff were rude to her and threw her call light out of reach. The investigation included three resident reviews. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, facility investigative file review, staff and family interviews the facility failed to thoroughly investigate when Resident #3 reported staff was rude to her and removed her call light out of reach. The facility also failed to complete a thorough investigation when Resident #4 reported staff were mean to her. Three residents were reviewed related to this investigation. The facility reported a census of 26 residents.

Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to complete a comprehensive Care Plan for 2 of 7 residents (Residents #5 and #9) after their admission. The facility reported a census of 26 residents.

Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to update 3 of 3 resident's Care Plans (Resident #1, #9 and #10) after they experienced a fall. The facility also failed to update 1 of 3 resident's (Resident #9) Care Plan when he developed a new pressure ulcer. The facility reported a census of 26 residents.

Inspectors wroteBased on record review, resident and staff interviews the facility failed to ensure 2 of 3 resident's (Resident #2 and #5) treatment orders were signed out as being completed. The facility reported a census of 26 residents.

Inspectors wroteBased on resident council notes, facility assessment review, resident and staff interview the facility failed to provide sufficient staff for safe transfers and assisting residents timely when needed. The facility reported a census of 26 residents.

Inspectors wroteBased on record view, resident and staff interviews the facility failed to ensure 3 of 10 resident's (Resident #7, #8, and #10) records were complete and accurate. The facility reported a census of 26 residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that proper infection control measured were used during food service. While preparing the lunch meal Staff F applied disposable gloves, then touched several surfaces before touching food. The facility reported a census of 22 residents.

Inspectors wroteBased on personnel file review, staff interview, and policy review the facility failed to ensure that all staff completed the required Dependent Adult Mandatory Reporter Training for 1 of 5 staff reviewed. The facility reported a census of 22 residents.

Inspectors wroteBased on electronic health record review (EHR), resident interviews, staff interviews and policy review the facility failed to provide dignity and respect during personal cares to 2 of 22 residents reviewed (Resident #8 and #175). The facility reported a census of 22 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, and staff interviews the facility 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). The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to follow professional standards of quality for 2 of 4 residents reviewed. Resident #172 had a low blood glucose reading, staff failed to document the reading and failed to follow up with a second check. Resident #9 had low blood pressure readings and staff failed to establish parameters to determine when to hold his hypertension medication. The facility reported a census of 22 residents.

Inspectors wroteBased on interviews with facility staff and healthcare services, policy and record review the facility failed to ensure that follow up services and appointments were established before discharge for 1 of 3 residents reviewed. Resident #173 was discharged to a hotel without securing home health services or follow up appointments with the doctor. The facility reported a census of 22 residents.

Inspectors wroteBased on staff interviews, clinical record review and policy review the facility failed to assess pain and failed to complete vitals and complete a comprehensive assessment prior to transfer out for 1 of 4 residents reviewed. Resident #171 experienced severe pain related to a fracture and staff failed to assess pain levels, administer pain medication and notify the physician per the plan of care. The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review, observations, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing personal care and providing catheter care to a resident that was on Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #2 and #180). The facility reported a census of 22 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to appropriately implement interventions to protect 1 out of 2 female residents from possible sexual abuse. The facility further failed to appropriately implement interventions to protect 1 out of 1 male residents from possible physical abuse by Resident #182. The facility reported a census of 25 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to complete a thorough investigation for possible abuse by not interviewing all the witnesses for 2 of 3 incidents reviewed against 2 residents (Resident #183 and #184). The facility reported a census of 25 residents.

Inspectors wroteBased on document review, policy review, and staff interview the facility failed to provide treatment or services to a resident that had decreased range of motion to prevent further decrease in range of motion for 1 of 12 residents reviewed (Resident #22). The facility reported a census of 25 residents.