Ocean Park Healthcare: Mental Health Misdiagnosis - CA
Ocean Park Healthcare on Pico Boulevard was cited by federal inspectors in May after staff admitted they "mistakenly" listed schizophrenia as an active diagnosis for a resident who showed no symptoms of the disorder. The woman, identified as Resident 12, appeared calm and cooperative during inspections and told investigators she was "doing well" and enjoyed participating in activities.
The Minimum Data Set nurse who conducted the assessment acknowledged the error during interviews with inspectors on May 4. The nurse said they lacked "all documentation that supports the diagnosis according to DSM-V," the official manual used by mental health professionals to diagnose psychiatric disorders.
Resident 12 was readmitted to the facility earlier this year with legitimate diagnoses including chronic pulmonary edema, atrial fibrillation, and anxiety disorder. Her cognitive skills were severely impaired, according to her assessment. But when inspectors observed her on May 2, she appeared compliant with care and followed directions without issue.
The nursing staff member responsible for the assessment told inspectors that Resident 12 "is cooperative and does not show any hallucinations, and delusions" — key symptoms required for a schizophrenia diagnosis.
Director of Nursing confirmed the facility's failure during interviews with inspectors. The director stated that residents "need to meet all criteria before they quote them with a schizophrenia diagnosis on the MDS" and emphasized that "they need to have a medical professional that will provide the supporting documents."
The misdiagnosis violated federal standards requiring accurate resident assessments. According to clinical guidelines cited in the inspection report, diagnosing schizophrenia requires at least two specific symptoms present for a significant portion of time during a one-month period, including delusions, hallucinations, or disorganized speech.
Ocean Park Healthcare also failed to complete required mental health screenings for two other residents with psychiatric conditions. Residents 1 and 25 both tested positive for initial mental health screenings that should have triggered more detailed evaluations, but facility staff never followed up to obtain the required assessments.
Resident 1 was admitted last July and readmitted this year with anxiety, dementia, and depressive disorder. The resident required assistance with daily activities and had cognitive impairment documented in their assessment. Despite testing positive for a Level I screening in November that required a follow-up evaluation, no Level II assessment was ever completed.
The same pattern occurred with Resident 25, who was admitted in June 2023 and readmitted in April with hypertension, anxiety, and major depressive disorder. This resident also had cognitive impairment and required staff assistance with daily activities, but never received the required follow-up mental health evaluation.
The Minimum Data Set nurse told inspectors that facility policy required the state mental health office to call within three days for follow-up, but if they didn't call, "then the facility has to follow up." The nurse admitted there was "no documented evidence" that either the state office called or that the facility made any follow-up contact.
The Director of Nursing explained that these screenings "evaluate the placement of the resident's care into the facility" and determine "if residents need a referral to mental health and obtain resources needed for the residents." The director warned that failing to complete the assessments "may lead to a delay in care and the residents will not have proper follow-up care like mental health care."
Inspectors also found Ocean Park Healthcare using bed rails on a resident without proper authorization or safety planning. Resident 10, who has encephalopathy, chronic obstructive pulmonary disease, and dementia, was observed lying in bed with both side rails raised on May 4.
The facility had no physician's order for the bed rails and no care plan addressing their use, despite the resident's severe cognitive impairment. A registered nurse who observed the setup told inspectors that "there should be an order and a Care Plan for the use of bed siderails" and warned that "the side rails may cause harm to Resident 10 if it's being used in a wrong way like restricting resident's movement."
The facility's own policy acknowledges that bed rails can constitute restraints when residents cannot remove them independently. The policy specifically prohibits "using bedrails to keep a resident from voluntarily getting out of bed" and requires care plans that address underlying problems causing the need for such interventions.
The Director of Nursing confirmed that "there must be a CP developed for the use of devices that may restrict resident's movement" but admitted "there was no CP developed for Resident 10's used of bed siderails."
All violations were classified as causing minimal harm or potential for actual harm, affecting few residents. The inspection was completed May 4, 2025.
The citation for inaccurate mental health diagnosis represents a particularly concerning failure given the potential impact on treatment decisions and care planning. Schizophrenia carries significant clinical implications that could affect medication choices, therapy approaches, and long-term care strategies — none of which were appropriate for Resident 12 based on her actual condition and behavior.
Ocean Park Healthcare's failure to complete required mental health screenings for residents with documented psychiatric conditions also raises questions about whether other residents are receiving appropriate specialized services for their mental health needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ocean Park Healthcare from 2025-05-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
OCEAN PARK HEALTHCARE in SANTA MONICA, CA was cited for violations during a health inspection on May 4, 2025.
The Minimum Data Set nurse who conducted the assessment acknowledged the error during interviews with inspectors on May 4.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.