The contradiction appeared in documents dated just one day apart in May 2025. On May 16, a health status note indicated Resident 1 was "on monitoring for behavior of wandering." The next day, the facility's Minimum Data Set assessment — the federal tool used to determine care needs and services — stated the resident had no wandering behaviors.
Federal inspectors discovered the discrepancy during a November complaint investigation. The error had the potential to affect the resident's care and services, according to the inspection report.
Resident 1 was admitted to the facility with multiple diagnoses including schizoaffective disorder, anxiety disorder, anemia, and peripheral venous insufficiency. Schizoaffective disorder is a mental illness that can affect thoughts, mood, and behavior. The resident's History and Physical from May 14 indicated they had the capacity to understand and make decisions.
The May 17 assessment showed Resident 1 had moderate cognitive impairment and required supervision or touching assistance for activities of daily living like bathing, dressing, and toileting.
When inspectors confronted the Director of Nursing with the contradictory documents on November 18, she confirmed there was a discrepancy in the assessment. She stated she was not aware of the error but added that wandering behaviors "are not uncommon" for new residents.
The facility's own policy on wandering and elopements, reviewed in January 2025, states that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.
Another facility policy on resident assessment indicates that a comprehensive assessment of every resident's needs must be made, including completion of the Minimum Data Set. The policy states that the interdisciplinary team uses the federally mandated MDS form to conduct resident assessments, and all members of the care team are asked to participate in the assessment process.
The Minimum Data Set serves as more than just paperwork. It directly influences the level of care residents receive and determines what services facilities provide. An inaccurate assessment can result in residents not getting the monitoring, interventions, or safety measures they need.
For residents with wandering behaviors, proper assessment typically leads to specific safety protocols, environmental modifications, and increased supervision. When assessments fail to capture these behaviors, residents may not receive appropriate safeguards.
The inspection found that University Park Healthcare Center failed to accurately assess wandering behaviors for one of three sampled residents. Federal inspectors determined this constituted minimal harm or potential for actual harm.
Wandering is a significant safety concern in nursing homes, particularly for residents with cognitive impairment like Resident 1. Facilities are required to identify residents at risk and implement appropriate interventions while maintaining the least restrictive environment possible.
The assessment failure represents a breakdown in the facility's interdisciplinary team process. Multiple staff members should have been involved in completing the resident assessment, yet the obvious contradiction between the health status note and the MDS went unnoticed until federal inspectors pointed it out months later.
The Director of Nursing's admission that she was unaware of the discrepancy raises questions about oversight and quality assurance processes at the facility. The MDS assessment is a critical document that should undergo review before finalization.
University Park Healthcare Center's policies appeared comprehensive on paper, emphasizing the importance of accurate assessments and wandering prevention. However, the implementation fell short when it came to ensuring consistency between different parts of a resident's record.
The case highlights how documentation errors can have real consequences for resident safety. When official assessments don't match clinical observations, residents may not receive the level of monitoring and intervention their conditions require.
Resident 1 continues to live at the facility with moderate cognitive impairment and multiple medical conditions. Whether the assessment discrepancy affected their actual care remains unclear from the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Healthcare Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for University Park Healthcare Center
- Browse all CA nursing home inspections