Staff at Chapters Living of Council Bluffs discovered the red area on Resident 30's right forehead at approximately 7:30 AM on January 4. The injury measured 3 centimeters by 2.5 centimeters and had become a raised "goose egg" by afternoon when the resident's daughter visited.
The facility's Director of Nursing told inspectors that staff should have immediately notified the physician, family, and nursing supervisor when they found the head injury that morning. Instead, the physician wasn't contacted until 7:27 PM — nearly 12 hours later. The resident's daughter received notification around the same time.
"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," according to the inspection report.
Resident 30 had been "aggressive and combative" the night before the injury was discovered. She kicked one employee in the groin and hit another staff member during the incident. The resident later told staff she had hit her head on the bedside table on the morning of January 4.
The Director of Nursing concluded the injury likely occurred during the combative episode the previous evening, despite the resident's account of hitting the bedside table.
Staff also failed to begin required neurological assessments when they discovered the head injury. The facility's policy required immediate neuro checks for any unexplained head trauma, but assessments didn't start until 6:00 PM — more than 10 hours after the injury was found.
The Nurse Practitioner who received the delayed notification expressed concern about the facility's response. She told inspectors on January 13 that "she would expect staff to call with any head injuries and start neuro assessments immediately."
The resident's daughter initially received notification about the injury, but when she arrived at the facility that afternoon and saw the raised hematoma, she questioned staff about it. The Director of Nursing suggested the daughter "must have forgotten about the earlier notification."
Medical records show the hematoma was significant enough that staff held the resident's blood pressure medication that evening due to low blood pressure and slow heart rate. The on-call provider didn't return the facility's call about these vital sign changes.
The resident had showered the day before the injury was discovered, but staff interviewed during the investigation said she had not fallen during bathing. Multiple staff members confirmed the combative behavior the night before the injury appeared.
The Director of Nursing told inspectors she would have initiated neurological assessments immediately if she had known about the head injury when it was first discovered. She explained that neuro checks were especially important because she initially thought the resident might be on blood thinners, which would increase bleeding risks with head trauma.
The Nurse Practitioner noted that staff reported the resident "gave several conflicting stories" about how the injury occurred, but she wasn't informed about the hematoma developing into a raised area or any other bruising on the resident.
The raised area on the resident's forehead decreased significantly within a day and was "almost gone" by the next morning, according to the Director of Nursing. No other injuries resulted from the incident.
Federal inspectors found the facility violated notification requirements by failing to promptly inform the physician, family, and nursing supervisor about the unexplained head injury. The delayed response prevented timely medical assessment and appropriate monitoring of a potentially serious condition.
The inspection report documented that "some writes came from that incident" regarding staff failures to follow proper notification procedures for unexplained injuries.
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.