Inspection·December 5, 2024

F 0689 f. Keep hot liquids away from the edges of the table; and Level of Harm - Minimal harm or potential for actual harm g. Do not refill containers while the resident is holding the container. Residents Affected - Few Review of the facility's P&P titled Accidents and Supervision revised 12/19/22, showed the resident's environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes identifying hazards and risks and implementing interventions to reduce hazards and risks. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is based on the individual resident's needs. 1. Review of the facility's letter to CDPH, L&C Program dated 11/19/24, showed an incident when Resident 1 spilled the hot chocolate on her left shoulder which extended down to the resident's posterior back. The letter showed Resident 1 experienced discomfort to the site and Resident 1 had developed blisters on her left shoulder and left upper back. Medical record review for Resident 1 was initiated on 12/4/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 9/6/24, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS dated [DATE], under the section for Functional Limitation in Range of Motion, showed Resident 1 had impairment on both upper extremities (shoulder, elbow, wrist, and hand). The section for Functional Abilities and Goals showed Resident 1 needed partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half he effort.) for eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Review of Resident 1's plan of care revised 10/26/23, showed a care plan problem addressing Resident 1's potential for cognitive loss related to episodes of forgetfulness. The interventions included to cue, reorient, and supervise as needed. Review of Resident 1's plan of care revised on 4/5/24, showed a care plan problem addressing Resident 1's ADL self-care performance deficits related to chronic osteoarthritis, hypertension, hyperlipidemia, polyneuropathy, morbid obesity, and gastroesophageal reflux. The interventions showed Resident 1 required assistance from the staff for eating. Review of Resident 1's Progress Note dated 11/15/24 at 0715 hours, showed Resident 1 was heard screaming for pain because she spilled hot cacao on herself and was noted with redness to her left shoulder,extending to the back. Further review of Resident 1's medical record failed to show documented evidence the assessment was completed for Resident 1's ability to handle containers and consume hot liquids. On 12/5/24 at 1130 hours, a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed awake and lying in bed with the head of the bed elevated at 45 degrees. Resident 1 was asked to describe her spillage incident on 11/15/24. Resident 1 stated she would only have the hot chocolate or coffee in the morning, and on 11/15/24, she was offered with the hot chocolate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555536 If continuation sheet Page 2 of 4 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 12/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that morning. Resident 1 stated she had just woken up and she was in the same position as she was now. Resident 1 stated she was not sitting in an upright position in bed. Resident 1 stated when she received thehot chocolate, she tried sipping the hot drink with the straw maybe twice. Resident 1 then placed the cup on the table in front of her after trying to sip it twice. Resident 1 further stated the next thing she remembered was screaming in pain because she spilled the hot chocolate on herself but could not remember if she fell asleep. On 12/5/24 at 1330 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 was assigned to her most of the times. CNA 2 stated Resident 1 was alert but confused at times. CNA 2 was asked to describe Resident 1's hot beverage spillage incident on 11/15/24. CNA 2 stated when she gave Resident 1 the hot chocolate, Resident 1 was awake and started drinking the hot chocolate. CNA 2 then went to see another resident. CNA 2 stated 15 minutes after she left Resident 1, she heard Resident 1 screaming so she went to see Resident 1 right away. CNA 2 stated she found the hot chocolate was spilled on Resident 1's left shoulder and her back. CNA 2 stated she observed Resident 1 crying because she was in pain. CNA 2 stated she started wiping Resident 1's body and called the nurse. CNA 2 further stated Resident 1 could eat by herself but would fall asleep at times and needed cuing. CNA 2 stated when she was not busy, she would sit with Resident 1 for the whole meal. On 12/5/24 at 1400 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 was assigned to him when Resident 1 had the hot liquid spillage incident. LVN 1 stated Resident 1 sustained redness on the left shoulder and back, and eventually developed blisters on those body parts. LVN 1 stated Resident 1 needed partial to moderate assistance with eating. LVN 1 stated Resident 1 needed to be cued multiple times and at times Resident 1 would fall asleep during meals. LVN 1 further stated Resident 1 should have a helper throughout the meal. LVN 1 stated there was no assessment done for Resident 1 regarding her ability to consume hot liquids. On 12/5/24 at 1620 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the nurses assessed the residents' ability to eat by themselves but did not perform an assessment specifically regarding the residents ' ability to handle a container and consume hot liquids. RN 1 verified Resident 1's medical record failed to show documented evidence the assessment was completed to determine Resident 1's ability to handle containers and consume hot liquids. On 12/5/24 at 1645 hours, an interview and concurrent medical record review was conducted with the OT 1. OT 1 stated the OT evaluation dated 9/6/24, showed Resident 1 had impairment in both upper extremities due to the resident's shoulder pain and the section under Self-Feeding showed Resident 1 was independent. OT 1 stated he only assessed in general how Resident 1 ate, handled the utensils and the cup. OT 1 stated the OT did not do a specific assessment of the residents' ability to handle and consume hot liquids. 2. Medical record review for Resident 3 was initiated on 12/5/24. Resident 3 was admitted in the facility on 3/30/22 and was readmitted on [DATE]. Review of Resident 3's H&P examination dated 11/18/23, showed Resident 3 had the capacity to understand and make decisions. Further review of Resident 3's medical record showed no evidence Resident 3 was assessed for her ability to handle containers and consume hot liquid. On 12/5/24 at 1620 hours, an interview and concurrent medical record review was conducted with RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555536 If continuation sheet Page 3 of 4 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 12/05/2024 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 0689 1. RN 1 verified there was no assessment performed to assess Resident 3's ability to handle containers and consume hot liquids as per the facility's P&P. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555536 If continuation sheet Page 4 of 4