Seacrest Post-Acute Care: Resident Found Outside Facility - CA
That finding came out of a complaint inspection at the facility at 1416 West 6th Street on September 10, 2025. Federal inspectors reviewed the case and found that nursing staff had not notified the resident's attending physician or the physician on call after the resident was discovered outside the building. The facility's own assistant director of nursing confirmed it should have happened.
The failure mattered because a resident being found outside a care facility is the kind of event that can signal a fall, a medical episode, or something worse. Without a physician's assessment, any injury or change in condition could go undetected. A delayed call is a delayed decision about whether that person needs treatment.
Seacrest's internal policy, last revised in February 2021, was explicit. When there has been an accident or incident involving a resident, the nurse is responsible for notifying the attending physician or the physician on call. The assistant director of nursing, reviewing that policy with inspectors during a 1:47 p.m. interview on the day of the inspection, acknowledged directly that a resident being found outside the facility qualifies as exactly that kind of incident.
That acknowledgment made the lapse difficult to explain away. The policy existed. The staff knew what it required. The call was not made.
Inspectors rated the deficiency at the level of minimal harm or potential for actual harm, with few residents affected. That is the lower end of the federal harm scale, and it reflects that inspectors did not find documented injury resulting from the missed notification in this case. But the rating captures what was observed, not necessarily what could have followed. A physician who is never called cannot order imaging for a fall that staff assumed was minor. A physician who is never called cannot adjust medications, order observation, or decide whether a transfer to a hospital is warranted.
The question inspectors could not fully answer from the record alone is how long the resident had been outside before being found, and what condition they were in when they were. The inspection narrative does not detail those circumstances. What it does establish is that once the resident was found, the response was incomplete.
Seacrest Post-Acute Care Center is a short-term rehabilitation and long-term care facility serving the San Pedro community on the southern edge of Los Angeles. The residents it serves are, by definition, people who need medical oversight. They are there because they cannot manage their conditions independently. The physician notification requirement exists precisely because staff on the floor are not always positioned to recognize when something that looks routine is not.
The assistant director of nursing did not dispute the finding. In the concurrent interview with inspectors, she confirmed the resident being found outside should have triggered a call. That kind of candor in an inspection interview can reflect well on a facility's willingness to acknowledge problems. It does not change what happened to the resident who was found outside and whose doctor spent that time without knowing.
Inspectors classified this as a complaint inspection, meaning someone, a resident, a family member, or a staff member, raised a concern that prompted the visit. The September 10 inspection was the response to that concern.
The facility was required to submit a plan of correction. What that plan contains, and whether it resulted in any change to how staff handle similar incidents going forward, is a matter between Seacrest and the state survey agency.
What the record shows is simpler than any corrective plan. A resident ended up outside the building. The nurse did not call the doctor. The facility's own policy said to call the doctor. The assistant director of nursing agreed that was the right call to make. It was not made.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seacrest Post-acute Care Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
SEACREST POST-ACUTE CARE CENTER in SAN PEDRO, CA was cited for violations during a health inspection on September 10, 2025.
That finding came out of a complaint inspection at the facility at 1416 West 6th Street on September 10, 2025.
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.