Staff discovered the red area on Resident 30's right forehead at approximately 7:30 AM on January 4. They didn't contact her physician until 7:27 PM that evening — a delay that violated the facility's own protocols for head injuries.
The resident had been "aggressive and combative" the night before the injury was discovered, according to the facility's director of nursing. She had kicked one employee in the groin and hit another employee during the evening of January 3.
Staff found the injury had progressed from a red area in the morning to a raised hematoma measuring 3 centimeters by 2.5 centimeters by evening. The facility's nurse practitioner said she expected immediate notification of any head injuries and neurological assessments to begin right away.
Instead, neurological assessments didn't start until 6:00 PM on January 4 — nearly 11 hours after the injury was first noticed.
The resident told staff she had hit her head on her bedside table on the morning of January 4. But the director of nursing believed the injury likely occurred during the resident's combative episode the evening before.
When the resident's daughter visited the facility later on January 4, she asked about the raised area on her mother's forehead. The director of nursing said the daughter "must have forgotten about the earlier notification" — but records show no family notification occurred until evening.
The facility's nurse practitioner said staff reported the resident "gave several conflicting stories" about how the injury occurred. She was not informed about the progression from a red area to a "goose egg" hematoma throughout the day.
Staff documented the injury as being of "unknown origin" in their evening physician notification. The director of nursing later told inspectors she had completed an investigation and determined the injury was no longer of unknown origins, but this conclusion came after the delayed reporting had already occurred.
The director of nursing acknowledged multiple protocol failures. She said she expected staff to notify her immediately when the injury was found at 7:30 AM, but they didn't. She expected the nurse to notify the physician at 7:30 AM when the area was discovered, but that didn't happen either.
She also expected the resident's family to be notified at 7:30 AM when the injury was first noticed, but no family contact occurred until evening.
The director of nursing told inspectors she would have initiated neurological assessments immediately if she had known the resident was on blood thinners and had a head injury. However, when she asked about blood thinners, Staff M told her the resident was not on any.
Medical records show the resident's evening blood pressure medication was held on January 4 due to low blood pressure and a slow pulse rate. Staff called to inform the on-call provider but received no return call.
The raised area on the resident's forehead decreased and was "almost gone" by the next day, according to the director of nursing. She said there were no other injuries from the incident.
The nurse practitioner emphasized that immediate neurological monitoring is critical for head injuries in elderly residents. The 12-hour delay in physician notification and family contact violated basic safety protocols designed to catch complications early.
Federal inspectors cited the facility for failing to ensure residents received proper care and services. The violation affected few residents but posed minimal harm or potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chapters Living of Council Bluffs from 2026-01-30 including all violations, facility responses, and corrective action plans.