Inspection·March 21, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follows: cleanse with normal saline, pat dry apply medihoney (medical honey which hastens the healing of wounds through its anti-inflammatory effects), cover with a foam dressing, every day shift (every shift) for 21 days. - dated 3/15/24, showed to perform treatment to the scattered abdominal open wounds as follows: cleanse with normal saline, pat dry, apply Bactroban ointment, apply an abdominal pad, cover with a dry dressing every day shift (every shift) for skin irritation due to recent GTinsertion for 21 days. On 3/20/24 at 1324 hours, a wound care observation for Resident 2 was conducted with LVN 1. Resident 2 was observed being awake in bed. LVN 1 was observed washing her hands with soap and water and donning a clean pair of gloves. LVN 1 was observed removing the dressing from Resident 2's GT site. LVN 1 was observed changing her gloves and performing hand hygiene, and donning a clean pair of gloves. LVN 1 then proceeded to cleanse the GT site with normal saline and patted it dry with the gauze, applied a T-drain dressing and secured with the tape. LVN 1 then was observed changing her gloves and performing hand hygiene and donning a clean pair of gloves. LVN 1 proceeded to cleanse scattered abdominal open wounds with normal saline, patted dry, applied an abdominal pad and covered the wound with the dry dressing. LVN 1 was not observed applying Bactroban ointment on the scattered abdominal open wounds. LVN 1 then was observed changing her gloves and performing hand hygiene and donning a clean pair of gloves. LVN 1 then proceeded to cleanse left upper chest scattered scratches with normal saline, patted it dry, applied hydrocortisone ointment (medicated ointment) and left it open to dry. LVN 1 was not observed to perform wound care on the sacrococcyx Stage 2 pressure injury for Resident 2. Review of Resident 2's TAR dated 3/1/24 to 3/21/24, showed the following: - Treatment for scattered abdominal open wounds, cleanse with normal saline, pat dry, apply Bactroban ointment, apply anabdominal pad and cover with a dry dressing showed the signature of LVN 1 on 3/20/24. - Treatment for sacrococcyx Stage 2 pressure injury, cleanse with normal saline, pat dry, apply medihoney (medical-grade honey used for wound care), cover with a foam dressing, showed the signature of LVN 1 on 3/20/24. On 3/20/24 at 1520 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 verified she did not apply Bactroban ointment on the scattered open abdominal wound and did not perform wound care treatment on the sacrococcyx Stage 2 pressure injury during wound care treatment on 3/20/24 at 1324 hours, for Resident 2. However, LVN 1 verified she signed the TAR showing she applied the Bactroban ointment on scattered open abdominal wound and provided treatment to the sacrococcyx Stage 2pressure injury for Resident 2 on 3/20/24. LVN 1 stated the Bactroban ointment for Resident 2 was not available in the facility, so she did not apply the medication during the wound care. LVN 1 acknowledged she should have notified the resident's physician or had followed up with the pharmacy before she provided wound care treatment for Resident 2. LVN 1 further stated she needed another staff assistance to provide treatment to the sacrococcyx (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555536 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Regency Care Center 1770 W. LA Habra Blvd. LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Stage 2 pressure injury for Resident 2, so she was not able to provide the treatment during wound care observation on 3/20/24 at1324 hours. LVN 1 acknowledged she should not have signed the TAR for the treatment to the sacrococcyx Stage 2 pressure injury on 3/20/21, when she did not provide the treatment. On 3/20/24 at 1539 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified and acknowledged the above findings. The DON stated when the Bactroban medication was not available, the LVN should have followed up with the pharmacy and/or physician before providing treatment to the Resident 2. The DON stated LVN should not have signed the TAR when she did not provide treatment on the sacrococcyx Stage 2 pressure injury for Resident 2. 2. During the wound care observation and concurrent interview on 3/20/24 at 1520 hours, LVN 1 stated the Bactroban ointment for Resident 2 was not available in the facility, so she did not apply the medication during the wound care. However, review of Resident 2's TAR dated 3/1/24 to 3/21/24, showed a treatment entry with a start date of 3/16/24, for the resident's scattered abdominal open wounds, to cleanse with normal saline, pat dry, apply Bactroban ointment, apply an abdominal pad, and cover with a dry dressing every day shift (every shift) for skin irritation due to recent GT insertion for 21 days. Further review of the TAR showed the above treatment was performed on 3/16, 17, 18, and 3/19/24. On 3/21/24 at 1159 hours, a concurrent interview and medical record review for Resident 2 was conducted with the DON. The DON verified the physician's order for Resident 2' scattered abdominal open wounds showed to apply Bactroban ointment. When asked the DON to show when the Bactroban medication was delivered from the pharmacy for Resident 2, the DON was not able to show the documentation if the Bactroban ointment was delivered by the pharmacy for Resident 2, and if the medication was available for the wound care on 3/16, 17, 18, and 3/19/24. The DON further stated there was an error in the system while submitting an order to the pharmacy for the Bactroban ointment for Resident 2. The DON acknowledged she was not able to verify if the Bactroban ointment was applied during wound care for Resident 2 on 3/16, 17, 18, and 3/19/24, when the Bactroban ointment was not delivered by the pharmacy. The DON stated the licensed nurses should have followed up with the pharmacy or the physician when the ointment was not available on the above dates for Resident 2. On 3/21/24 at 1217 hours, a telephone interview was conducted with the Pharmacy Technician. The Pharmacy Technician stated the Bactroban ointment for Resident 2 was not ordered and delivered by the pharmacy before 3/21/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555536 If continuation sheet Page 3 of 3