The resident, identified as Resident #30, had been "aggressive and combative" the night before the injury was discovered on January 4. The Director of Nursing told inspectors the resident had kicked one employee in the groin and hit another employee during the evening of January 3.
By morning, staff found the red area on the right side of Resident #30's forehead. The resident told staff she had hit her head on the bedside table that morning, but the Director of Nursing believed the injury likely occurred during the previous night's aggressive episode.
The facility's own protocols required immediate action. Staff should have notified the Director of Nursing, the physician, and the resident's family at 7:30 AM when the injury was discovered. Neurological assessments should have begun immediately for any head injury of unknown origin.
None of that happened.
The Director of Nursing wasn't notified until later. The physician didn't receive word until evening. The family learned about it when the resident's daughter arrived that afternoon and noticed the area had become raised.
"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," inspectors wrote. "The DON stated she expected the nurse would have notified the physician of the area on the head at 7:30 AM when it was found as well and that was not completed."
By 7:49 PM that evening, more than 12 hours after discovery, Staff M finally documented the injury in the resident's electronic health record. The entry described it as "a hematoma to the right side of the forehead" and noted that the on-call provider, Director of Nursing, and the resident's daughter had been made aware.
A fax to the physician at 7:27 PM described the injury as a "3 cm x 2.5 cm hematoma to the right forehead of unknown origin." The same evening, staff held the resident's propranolol medication due to low blood pressure and a slow pulse, calling the on-call provider with no return call.
Neurological assessments didn't begin until 6:00 PM, nearly 11 hours after the injury was found. The facility's neurological assessment flow sheet confirmed the delay.
The resident's daughter had been notified earlier about the red area but apparently forgot, according to the Director of Nursing. When she arrived that afternoon and saw the area had become raised, she asked about it again.
"The DON stated Resident #30's daughter must have forgotten about the earlier notification," the inspection report stated.
The raised area decreased and was almost gone the next day, with no other injuries from the incident, the Director of Nursing told inspectors.
A Nurse Practitioner interviewed on January 13 confirmed she was notified on January 4 about the forehead area. Staff reported the resident gave "several conflicting stories" about how the injury occurred. The Nurse Practitioner said she wasn't told about any "goose egg" formation after the initial contusion or bruising elsewhere.
"The Nurse Practitioner stated she would expect staff to call with any head injuries and start neuro assessments immediately," inspectors noted.
The Director of Nursing explained to inspectors that she would have started neurological assessments immediately if the resident had been on blood thinners and sustained a head injury of unknown origin or showed changes in cognition. She had asked Staff M whether Resident #30 was on blood thinners and was told no.
The Director of Nursing completed an investigation after the fact, interviewing staff about the incident. Staff confirmed the resident had showered the day before but hadn't fallen. They described the resident's aggressive behavior the previous evening but failed to connect it to the morning's discovery of the head injury.
The facility received a citation for minimal harm with few residents affected, but the violation highlighted systematic failures in emergency notification protocols for head injuries requiring immediate medical attention.
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.