Federal inspectors found the facility failed to follow its own discharge planning procedures for the resident, who also had anxiety disorder, anemia, and peripheral venous insufficiency. The incomplete documentation left gaps in equipment needs, special observations, training instructions, and post-discharge goals.
Registered Nurse Supervisor 1 confirmed during the November 18 inspection that the discharge plan was missing crucial information. The document did not indicate who developed the plan, what equipment the resident would need, or what special observations were required. Post-discharge goals were blank.
The supervisor also noted missing signatures. Neither the staff member who completed the plan nor the resident had signed the document, as required by facility policy.
"I was unsure who filled out the document but thinks it was the night shift RN because that is how it is typically done," the supervisor told inspectors. "Also the resident should have signed."
The resident had been admitted to the facility with multiple complex conditions. Medical records from May showed the resident had capacity to understand and make decisions, but also had moderate cognitive impairment requiring supervision for daily activities like bathing, dressing, and toileting.
University Park's own policy, reviewed in April, explicitly requires a comprehensive discharge planning process. The policy states that when a resident's discharge is anticipated, staff must develop both a discharge summary and post-discharge plan "to assist the resident to adjust to his/her new living environment."
The policy mandates that the interdisciplinary care team develop the plan with assistance from the resident and family. Required elements include the resident's stated discharge goals, availability of caregivers or support persons, and how the team will support the resident's transition to post-discharge care.
The policy also requires resident involvement in the planning process.
None of these elements were documented for the resident who left the facility.
The inspection report does not indicate whether the resident experienced problems after discharge due to the incomplete planning. Federal regulations require nursing homes to provide proper discharge documentation to ensure continuity of care and help residents transition safely to their next living situation.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. Inspectors reviewed three discharge cases and found problems with one.
The facility's failure to complete discharge documentation represents a breakdown in basic administrative procedures designed to protect vulnerable residents during care transitions. For a resident with mental illness and cognitive impairment, proper discharge planning becomes even more critical to ensure appropriate follow-up care and support services.
University Park Healthcare Center is located on East Adams Boulevard in Los Angeles. The November inspection was conducted in response to a complaint.
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
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