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Complaint Investigation

Ocean Park Healthcare

May 27, 2026 · Santa Monica, CA · 2828 Pico Boulevard
Citations 2
CMS Rating 2/5
Beds 41
Provider ID 555786
Healthcare Facility
Ocean Park Healthcare
Santa Monica, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

OCEAN PARK HEALTHCARE in SANTA MONICA, CA — inspection on May 27, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies

During an interview on 5/27/2026 at 1 PM,

and was keeping it close to the body. LVN 1 stated this instigated her to speak to physical therapy and ask about the plan for Resident 1. LVN 1 stated it was decided that Resident 1 to get an MRI so as to clear the resident prior to making changes on the resident's therapy plan. LVN 1 stated she arranged for the MRI and followed up with the imaging company on 5/6/2026 and the imaging company told LVN 1 that the results would take 3 days to come back. LVN 1 stated the imaging company emailed Resident 1's MRI results to the Assistant Director of Nursing's (ADON), however, LVN 1 did not know when the MRI results was emailed to the ADON.

During a concurrent interview and record review on 5/27/2026 at 1:46 PM, the ADON stated Resident 1's MRI results was emailed to the ADON's work email on 5/11/2026 at 1:34 PM.

The ADON stated the facility did not report to the Resident 1's MRI results to the physician on 5/12/2026 because the ADON left the facility prior to the email coming in and that no one else in the facility has access to the ADON's email.

The ADON stated critical test results are relayed to the physician immediately.

The ADON further stated that on 5/12/2026, ADON notified the Director of Nursing (DON) of Resident 1's MRI results.

The ADON did not respond when asked what would to residents if the ADON is not at work and or unable to access the residents' diagnostic tests results.

During an interview on 5/27/2026 at 2:50 PM, the DON stated Resident 1 fell on a Sunday, 4/12/2026, and was transferred to a GACH that day.

The GACH performed an x-ray which did not show a fracture.

The DON stated Resident 1 continued to have pain, so the physician ordered an MRI for the resident.

The DON further stated Resident 1's MRI result was emailed to the ADON work email.

The DON further stated the facility reported Resident 1's fractures on 5/13/2026 to the SSA.

The DON further stated that, we must report a fracture to the SSA within 24 hours to allow the state can investigate and make sure we competently cared for the resident.

The DON stated, we must work on this (accessing results) when asked what can happen to residents if the DON is not at work and or unable to access the residents' diagnostic tests results. A review of the facility's policy and procedures, Unusual Occurrence Reporting, dated 2/2026, indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.

The P&P also indicated, our facility will report the following events to appropriate agencies:g.

Allegations of abuse, neglect and misappropriation of resident property; andh.

Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors.2.

Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

555786 05/27/2026

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405

etc.) should follow or coordinate the procedure.

Identifying Situation that Warrant Immediate

requested to be notified as soon as a result is received.

Whether the result should be conveyed to a

any other factors).

Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA MONICA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OCEAN PARK HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.