The resident had been aggressive and combative the night before, kicking one employee in the groin and hitting another. She told staff she hit her head on the bedside table that morning, but the facility's director of nursing said the injury probably occurred during the previous evening's altercations.
By 7:49 PM, more than 12 hours after the injury was first noticed, Staff M documented that Resident 30 had developed a hematoma on the right side of her forehead. The skilled note recorded that the on-call provider had been made aware, along with the director of nursing and the resident's daughter.
The daughter visited that afternoon and asked about the area on her mother's forehead, which had become a raised bump. The director of nursing said the daughter "must have forgotten about the earlier notification," though records show no family contact occurred until evening.
Staff failed to initiate required neurological assessments when the head injury was discovered. The facility's neurological assessment flow sheet shows monitoring didn't begin until 6:00 PM on January 4, nearly 11 hours after staff first observed the injury.
The director of nursing acknowledged multiple protocol violations during the incident investigation. She said staff should have notified her immediately at 7:30 AM when the injury was found. The nurse should have contacted the physician at that time as well, she said, and the family should have been informed when the injury was first noticed.
Neurological assessments should have started immediately upon discovering the forehead injury, the director said, not hours later.
A physician notification fax sent at 7:27 PM documented the hematoma as measuring 3 centimeters by 2.5 centimeters and noted it was of "unknown origin." The same evening, staff held the resident's propranolol medication due to low blood pressure and slow pulse, calling the on-call provider with no return call recorded.
The nurse practitioner who received the delayed notification said she expected staff to call immediately about any head injuries and start neurological assessments right away. She told inspectors on January 13 that staff reported Resident 30 gave "several conflicting stories" about how the injury occurred.
The nurse practitioner said she wasn't informed about the "goose egg" that developed after the initial contusion or about any other bruising on the resident.
Resident 30's injury developed during what the director of nursing described as an aggressive episode the previous evening. The resident had physical altercations with staff but received a shower the day before without falling, according to staff interviews.
The director said she determined the injury was no longer of unknown origins after completing her investigation. She interviewed staff who confirmed the resident's combative behavior but said no fall occurred during her shower.
The raised area on Resident 30's forehead decreased and was "almost gone" the next day, the director said. She reported no other injuries resulted from the incident.
The director explained she would have initiated neurological monitoring immediately if the resident had been taking blood thinners and sustained a head injury of unknown origin, or if there had been changes in cognition. However, when Staff M confirmed Resident 30 wasn't on blood thinners, the director said she didn't start the assessments that should have begun regardless.
Federal inspectors cited the facility for failing to ensure immediate and appropriate care for the head injury, including delayed physician notification, family communication, and neurological monitoring protocols.
The violation affected few residents but represented minimal harm or potential for actual harm, according to the inspection findings completed January 30.
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.