University Park Healthcare Center: Care Plan Failures - CA
The policy, dated January 16, 2025, committed the facility to developing a comprehensive, person-centered care plan for each resident within seven days of completing a required assessment. The plan was supposed to include measurable objectives, timetables, and specific goals tied to each resident's physical, psychosocial, and functional needs. Problem areas would be identified. Risk factors would be documented. Interventions would address underlying causes, not just symptoms.
That is what the policy said.
A separate policy, also dated January 16, 2025, governing the facility's interdisciplinary care planning team, repeated the same promise: individualized, comprehensive care plans, completed within seven days of each resident's assessment. Two documents. The same commitment. Both signed off less than a year before inspectors walked in.
The inspection, triggered by a complaint rather than a routine survey cycle, found deficiencies under federal tag F0600, which covers the right of residents to be free from abuse, neglect, and exploitation. CMS rated the level of harm as minimal harm or potential for actual harm. A few residents were affected.
University Park Healthcare Center sits at 230 East Adams Boulevard in Los Angeles, a neighborhood in South Los Angeles. The facility's identification number with CMS is 056206.
The gap between a facility's written policies and what actually happens to residents is one of the oldest problems in nursing home oversight. Policies are written for surveyors. They describe a world of careful clinical decision-making, interdisciplinary teamwork, and individualized attention. The inspection report filed after this visit described something different.
Care plans matter in ways that are not abstract. When a resident arrives at a skilled nursing facility, often after a hospitalization, often with multiple conditions, the care plan is the document that coordinates what every nurse, aide, therapist, and physician is supposed to do and when. Without one, or without one built on an actual assessment of that specific person, care defaults to routine. What the resident needs and what the resident gets can quietly diverge.
The facility's own policy acknowledged this. It stated that interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. It stated that when possible, interventions should address the underlying source of a problem, not just symptoms and triggers.
Those are not small commitments. They describe a facility that has thought seriously about what good care planning requires. They also set a standard against which the facility's actual practice can be measured.
Inspectors found that standard was not being met for at least some residents. The report does not describe what happened to those residents as a result. It does not name them. It does not say whether their conditions worsened, whether their needs went unmet in ways they or their families noticed, or whether the missing or inadequate care plans produced any documented harm. CMS rated the harm level as minimal or potential rather than actual and serious.
But potential harm in a nursing home is not a theoretical category. Residents in skilled nursing facilities are, by definition, people whose conditions require more support than they can manage at home. The assessment that feeds a care plan is the mechanism by which the facility learns what a resident actually needs. A care plan built without that foundation, or not built at all within the required window, is a plan built on guesswork.
University Park Healthcare Center's own interdisciplinary team policy described its purpose plainly: to develop an individualized comprehensive care plan for each resident. For a few residents seen by inspectors in November 2025, that purpose had not been carried out.
The facility's plan of correction was not included in the inspection documents reviewed for this report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Healthcare Center from 2025-11-10 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 22, 2026 · Our methodology
UNIVERSITY PARK HEALTHCARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on November 10, 2025.
The plan was supposed to include measurable objectives, timetables, and specific goals tied to each resident's physical, psychosocial, and functional needs.
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.