LOS ANGELES, CA - Federal inspectors cited University Park Healthcare Center for widespread failures including medication errors, inadequate medical care, failure to protect residents from physical abuse, and deficient range of motion therapy that led to preventable pressure injuries.
Resident Safety Compromised by Aggressive Behavior
The most serious violation involved the facility's failure to protect two residents from physical abuse by another resident diagnosed with schizoaffective disorder bipolar type. On February 9, 2025, Resident 392 physically struck Resident 42 in their shared room. The following day, after being moved to a new room, Resident 392 attacked his new roommate, Resident 9, hitting him above the right eye while the victim was lying in bed.
The facility's failures were systemic. Despite Resident 392 having a documented history of aggressive behavior requiring antipsychotic medication, the facility had not developed a comprehensive care plan for his schizoaffective disorder. Records show Resident 392 was receiving Zyprexa for the condition, but staff failed to verify the diagnosis upon admission and implement appropriate behavioral monitoring protocols.
The attacks left lasting psychological trauma. Days after the incident, Resident 9 remained visibly upset and angry when discussing the assault. "Resident 9 stated he remained upset regarding the incident when Resident 392 hit him," according to inspection records. The facility's registered nurse consultant acknowledged that without proper care planning for the diagnosed condition, "there was a risk of Resident 392 to decline in behaviors since there was no schizoaffective care plan developed."
Medical experts emphasize that schizoaffective disorder requires specialized interventions including behavioral monitoring, trigger identification, and structured therapeutic approaches. When facilities fail to implement these protocols, residents with mental health conditions can experience deteriorating symptoms while other residents face increased safety risks.
Severe Range of Motion Failures Result in Preventable Injury
A particularly troubling case involved Resident 48, who developed a Stage IV pressure injury on her left middle finger due to the facility's failure to provide prescribed range of motion therapy and splinting. The resident, who had hemiplegia following a stroke, was ordered to receive passive range of motion exercises and wear a hand splint five times per week starting in August 2024.
Records reveal massive gaps in care delivery. From August 2024 through February 2025, Resident 48 missed numerous therapy sessions and frequently refused treatment. In November 2024 alone, the resident did not complete therapy on 12 days and refused treatment on another 12 days. Despite these documented refusals, nursing staff failed to notify physicians or develop alternative intervention strategies.
The consequence was severe. By January 2025, Resident 48's left hand had contracted into a permanent fist position with the thumb positioned beneath the index finger. This positioning caused the thumbnail to dig into the middle finger, creating a Stage IV pressure wound requiring surgical debridement. The wound treatment nurse explained that the injury could have been prevented: "the left middle finger wound could have been prevented by doing exercises for the left hand and putting on the hand splint."
Range of motion therapy serves a critical medical purpose. Without regular movement, joints can develop contractures - permanent shortening of muscles and tendons that severely limit mobility and cause pain. In Resident 48's case, the contracted hand position not only created a painful wound but also compromised her ability to perform basic self-care activities.
Fatal Case Raises Questions About Medical Monitoring
The inspection uncovered concerning circumstances surrounding the death of Resident 77, who was found unresponsive in his room and pronounced dead by paramedics. The resident had diagnoses including pneumonia, COPD, and dysphagia, requiring specialized respiratory care and swallowing interventions.
Multiple care failures preceded the death. The facility failed to implement ordered speech therapy interventions for swallowing difficulties, did not include physician-ordered oxygen therapy in the care plan, and allowed gaps in nursing assessments. Most troubling, vital signs documented by one licensed vocational nurse were identical across multiple shifts for several residents, raising questions about the accuracy of medical monitoring.
The facility's medical director emphasized the importance of regular assessments: "when there was no documentation staff would not know the resident's condition or needs and would not understand the trends of the resident's condition." The last skilled nursing assessment for Resident 77 was documented 16 hours before he was found unresponsive.
Respiratory care protocols also fell short. The facility failed to change oxygen equipment according to manufacturer guidelines and allowed tubing to remain on floors, creating infection risks. The infection preventionist confirmed that contaminated oxygen equipment "could result in a resident getting a lung infection."
Systemic Medication Safety Concerns
Inspectors documented a 22.22% medication error rate - more than four times the federal maximum of 5%. Errors included missed vitamin D supplements, omitted eye drops for dry eyes, and dangerous mixing of crushed medications without physician authorization.
One particularly concerning incident involved a nurse attempting to crush and mix four different medications together for administration to a resident. The medications included escitalopram (for mental health), hydrochlorothiazide and losartan (for blood pressure), and aspirin (for blood clot prevention). Such mixing can alter drug effectiveness and create dangerous interactions.
The nurse acknowledged the risk: "crushing medications and mixing them together could cause them not to work as intended" and "could cause medical complications possibly resulting in hospitalization." Industry standards require each crushed medication to be administered separately to ensure proper absorption and prevent adverse interactions.
Additional Issues Identified
Federal inspectors documented numerous other violations affecting resident care:
Inadequate fall risk assessments that failed to account for prescribed medications and medical conditions, potentially placing residents at increased fall risk.
Missing colostomy care orders for a resident with a surgical opening, despite the resident having the condition for nearly two years.
Improper food preparation including incorrect texture modification for residents with swallowing difficulties and failure to follow fortified diet protocols for residents with weight loss.
Staffing qualification gaps including inability to locate certification records for restorative nursing assistants providing specialized therapy services.
Food safety violations involving improper storage temperatures, expired items, and inadequate labeling that could lead to foodborne illness.
The violations demonstrate systemic breakdowns in multiple areas of nursing home operations, from basic safety protocols to specialized medical care. The Centers for Medicare & Medicaid Services rated these deficiencies as causing actual harm or having potential for significant negative outcomes.
University Park Healthcare Center must submit a plan of correction addressing each violation and demonstrate sustained compliance with federal regulations. The facility's ability to continue receiving Medicare and Medicaid funding depends on successfully implementing corrective measures and maintaining regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Healthcare Center from 2025-02-13 including all violations, facility responses, and corrective action plans.
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