SANTA MONICA, CA - Federal inspectors cited the Rehabilitation Center of Santa Monica for failing to report unexplained injuries on a cognitively impaired resident, after staff across multiple shifts observed bruises on the resident's forehead and left cheek for days without notifying the physician, family members, or state authorities.
The August 2024 complaint investigation revealed a pattern of reporting failures that left a vulnerable dementia resident without proper medical evaluation and family notification for an extended period — in direct violation of the facility's own abuse reporting policies and federal nursing home regulations.
Bruises Discovered but Not Documented
According to the inspection report, the resident — identified as Resident 4 — was a readmitted patient with multiple serious diagnoses including dementia, dehydration, atrial fibrillation, psychosis, and difficulty walking. Medical records from May 2024 confirmed the resident was confused, had dementia, and lacked the capacity to make healthcare decisions. A June 2024 assessment confirmed severely impaired cognition.
The resident's most recent standardized assessment noted no skin problems to the forehead or left cheek, establishing that the bruises found later were new injuries.
The timeline reconstructed by inspectors reveals how the injuries went unreported across multiple staff members and shifts:
August 2, 2024 — LVN 1 observed a "shiny and pale green discoloration" on the resident's forehead and a "red and maroon-colored" left cheek at 7:05 AM. LVN 1 did not confirm whether any supervisor or the physician was notified. When asked why, LVN 1 told inspectors: "I was so focused on doing the paper charting, this is my first time charting on paper."
That same night, CNA 5 noticed "blue and purple discoloration" on the resident's forehead but did not report it to anyone.
August 4, 2024 — Between 4:30 PM and 5:00 PM, CNA 3 alerted LVN 2 to the bruises on the resident's forehead and cheek. LVN 2 confirmed seeing the injuries but waited approximately two to four hours before attempting to call the physician. LVN 2 told inspectors the delay occurred because "I was passing meds, and [Resident 4] was not complaining of pain."
When the physician, identified as MD 1, made rounds at the facility that same evening around 8 or 9 PM, LVN 2 did not notify the physician about the resident's facial injuries — despite the doctor being physically present in the building.
At 11:30 PM on August 4, CNA 5 again observed the bruises but did not report them, stating: "In my own assumption... in my knowledge, it was reported... I just thought it was there before, so I didn't report it."
August 5, 2024 — At the start of the overnight shift, LVN 5 noticed the resident's forehead and left cheek were "purplish in color." LVN 5 stated that LVN 2 said during the shift change report that the injuries had already been reported and that the physician was aware. When asked whether this was confirmed, LVN 5 told inspectors: "LVN 2 said it was reported so I didn't need to check it."
It was not until the morning of August 5 — between 7:00 and 7:30 AM — that RN 1 formally noticed the bruises and took action. Even then, the physician was not notified until 11:00 AM, roughly four hours later. When inspectors asked about the delay, RN 1 stated simply: "I got busy."
Family Left in the Dark
The reporting failures extended beyond the clinical staff. The resident's family members were never informed of the injuries by the facility.
Family Member 4 told inspectors that when Family Member 5 visited the facility on approximately August 1 or 2, the staff did not mention the bruises. From August 1 through August 5 — the day of the inspection — no family member had been contacted about the resident's facial injuries.
This directly contradicted the facility's own policy, which states that the administrator will inform the alleged victim's family of the progress of any investigation.
No Documentation, No Investigation
When inspectors reviewed the resident's medical chart with RN 1 on August 5, they found it was entirely lacking documentation related to the injuries. The chart contained no nursing progress notes, no physician orders, no physician progress notes, no skin assessment, no Medication Administration Record entries, no care plans, and no SBAR communication related to the forehead and cheek injuries.
For a resident with severely impaired cognition who cannot self-report or explain how injuries occurred, this absence of documentation is a significant clinical concern. Unexplained bruises on a dementia patient are classified as "injuries of unknown source" under federal regulations and trigger mandatory reporting requirements.
The facility's own policies — reviewed by inspectors — clearly require that all alleged violations, including injuries of unknown source, be reported to the state licensing agency within two hours when serious bodily injury is involved. The policies also mandate that all allegations of abuse and neglect be reported to state agencies and law enforcement.
Despite these policies, the facility's Administrator told inspectors on August 7 that because the facility's internal investigation concluded the resident was not abused, no report would be made to the California Department of Public Health, the Ombudsman, or law enforcement.
Why Delayed Reporting Is Medically Dangerous
Facial bruising on an elderly resident taking cardiac medications — including those for atrial fibrillation — carries specific medical risks that require prompt evaluation. Many cardiac patients take blood-thinning medications, which can cause bruising to spread and worsen. Bruising on the forehead can also indicate a head injury, which in an anticoagulated patient can progress to a life-threatening intracranial bleed even from a seemingly minor impact.
A delay of three to six days between initial observation and formal clinical evaluation means that any underlying head trauma would go unmonitored during the critical window when intervention could prevent serious complications. Standard clinical protocols call for neurological checks, imaging if indicated, and close monitoring when unexplained head and facial bruising is discovered on a patient with cognitive impairment.
The fact that the bruises changed color over the observation period — from "pale green" and "red/maroon" on August 2 to "blue and purple" by August 4 and "purplish" by August 5 — indicates the injuries were evolving, which typically signals ongoing tissue damage beneath the skin. This progression alone should have prompted urgent medical evaluation.
Systemic Breakdown in Abuse Reporting
The deficiency was cited under F-tag F609, which governs the timely reporting of alleged violations including abuse, neglect, and injuries of unknown source. Inspectors determined the facility failed to meet federal requirements for reporting.
What the inspection reveals is not a single employee's mistake but a systemic breakdown in the facility's reporting chain. At least seven staff members — including CNAs, LVNs, and an RN — either observed the injuries or were made aware of them across a span of multiple days. Each assumed someone else had handled the situation. No one confirmed that a report had actually been filed. No one documented the injuries in the medical record. No one called the family.
The facility was also cited under F-tag F600, related to protecting residents from abuse. The combination of unexplained injuries on a cognitively impaired resident, the absence of any investigation documentation, and the administrator's stated decision not to report to outside agencies represents a serious gap in resident protection.
Federal regulations require nursing homes to have systems in place that ensure every staff member understands their individual obligation to report suspected abuse or unexplained injuries — regardless of whether they believe someone else has already done so. The "assumption chain" documented at Santa Monica Rehabilitation Center is precisely the type of failure these regulations are designed to prevent.
What Should Have Happened
Under both federal regulations and the facility's own written policies, the first staff member to observe unexplained bruising should have immediately notified the charge nurse and documented the finding. The physician should have been contacted within the hour. The family should have been informed the same day. An incident report should have been completed, and a report filed with the California Department of Public Health within two hours.
None of these steps occurred in a timely manner.
The Rehabilitation Center of Santa Monica is located at 1338 20th Street in Santa Monica, California. The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center of Santa Monica from 2024-08-08 including all violations, facility responses, and corrective action plans.
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