Inspection·March 27, 2025

F 0689 bedand the bed was at the lowest position. Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's eINTERACT SBAR Summary for Providers dated 3/15/25 at 0540 hours, showed the resident had an unwitnessed fall and was sent to the acute care hospital for evaluation. Residents Affected - Few Review of Resident 2's nurses progress note dated 3/16/25 at 0313 hours, showed the resident was transferred back to the facility. Review of Resident 2's care plan dated 3/15/25, failed to include the information for the staff to identify which side of the bed the floor mat should be placed. On 3/27/25 at 1358 hours, an interview with LVN 2 was conducted. LVN 2 stated the bilateral floor mats were ordered by a physicianfor fall risk residents. On 3/27/25 at 1421 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated a physician's order was not needed for the floor mats because it was considered a nursing intervention for the residents. The DON further stated during a post-fall IDT meeting, the members would discuss and decide if the floor mats were needed and would update the resident's care plan. The DON stated Residents 1 and 2's floor mats were placed when the residents were readmitted to the facility. The DON reviewed Residents 1 and 2's care plans and verified the care plan did not address the use of the floor mat. 2. Review of the facility's P&P titled, Fall Prevention Program dated 12/28/23, showed to monitor the vital signs in accordance with facility policy, monitor for changes in resident cognition, and when any resident experiences a fall, the facility will document all assessments and actions. a. Medical record review for Resident 2 was initiated on 3/27/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's neurological flowsheet dated 3/15/25, showed the neurological assessment for item number 17 was missing. Review of Resident 2's eINTERACT SBAR Summary for Providers dated 3/15/25 at 0540 hours, showed the resident had an unwitnessed fall and was sent to the acute care hospital for evaluation. Review of Resident 2's Nurse Progress Note dated 3/16/25, showed at 0313 hours, the resident was transferred back at the facility. An interview and concurrent medical record review was conducted with the DON on 3/27/25 at 1421 hours. The DON stated the neurological assessments should be done for the residents with unwitnessed falls and should be documented on the neurological flowsheets. The DON reviewed Resident 2's neurological flowsheets and verified neurological assessment, Item Number: 17 was not completed. b. Medical record review for Resident 3 was initiated on 3/27/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's eINTERACT SBAR Summary for Providers dated 3/2/25 at 2051 hours, showed the resident had an unwitnessed fall. The primary care provider's recommendation was to conduct the neurological checks. (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 03/27/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 3's neurological flowsheet dated 3/2/25, showed the neurological assessment, Item Numbers: 6, 7, 12, 14, 15, and 18 were missing. On 3/27/25 at 1421 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the neurological assessments should be done for the residents with unwitnessed falls and should be documented on the neurological flowsheets. The DON reviewed Residents 2 and 3's neurological flowsheets and verified the neurological assessments were incomplete. Event ID: Facility ID: 555536 If continuation sheet Page 3 of 3