Health inspection·August 12, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to promote the healing of a pressure injury for one of three sampled residents (Resident 3). * The facility failed to provide a LAL mattress for Resident 3 who had a Stage 3 pressure injury (characterized by full-thickness skin loss, where the damage extends into the subcutaneous tissue (fat). While adipose tissue (fat) is visible, bone, tendon, or muscle are not exposed. The wound may have a crater-like appearance, and slough (dead tissue) or eschar (a scab) may be present, but they do not obscure the depth of the wound. Undermining and tunneling (where the wound extends under the skin's surface) can also occur). This failure had the potential to cause and delay the healing of resident's pressure injury. Findings: Review of the facility's P&P titled Pressure Injury Prevention and Management revised 9/12/23, showed in part, this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure injury, prevent infection and the development of additional pressure injury. Under Policy Explanation and Compliance Guidelines: the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Interventions will be documented in the care plan and communicated to all relevant staff. According to the NPIAP guidelines for pressure injury dated 2/2025, the goal of this international collaboration is to develop evidenced-based recommendations for the prevention and treatment of pressure injuries that can be used by health professionals throughout the world. The NPIAP staging system is a widely used classification for pressure injuries, which are skin damage caused by prolonged pressure. The NPIAP defines the Stage 3 pressure injury - as full thickness skin loss exposing subcutaneous tissue (deepest layer of the skin primarily consist of fat tissues, connective tissue blood vessels and nerves). On 8/7/25 at 1520 hours, an observation was conducted of Resident 3's wound care treatment with LVN 1. Resident 3's bed did not have a LAL mattress. On 8/7/25 at 1600 hours, an observation and concurrent interview was conducted with LVN 3 for Resident 3. LVN 3 stated Resident 3 was using a regular mattress and verified there was no LAL mattress on her bed. LVN 3 further stated Resident 3 should have a LAL mattress because she had a Stage 3 pressure injury. LVN 3 stated a LAL mattress would help relieve pressure on Resident 3's wound and promote healing. Medical record review for Resident 3 was initiated on 8/7/25. Resident 3 was admitted to the facility on [DATE], with diagnoses including a Stage 3 pressure injury measuring 3 cm (length) x 2 cm (width) x 0 cm (depth). Review of Resident 3's physician orders failed to show an order for a LAL mattress when she was admitted to facility. Review of Resident 3's care plan for the Stage 3 sacrococcyx (fused area at the spine and tailbone) pressure injury initiated 7/30/25, showed an intervention to have low air loss mattress for wound management. On 8/7/25 at 1610 Residents Affected - Few Page 1 of 2 555536 555536 08/12/2025 Park Regency Care Center 1770 W. LA Habra Blvd. LA Habra, CA 90631

F 0686 Level of Harm - Minimal harm or potential for actual harm hours, an interview was conducted with LVN 1. LVN 1 verified Resident 3 did not have a LAL mattress upon admission to the facility and had no physician's order for a LAL mattress. LVN 1 further stated Resident 3 should have had a LAL mattress because the resident had a Stage 3 pressure injury and it was the facility's protocol. On 8/12/25 at 1030 hours, an interview was conducted with RN 1. RN 1 stated it was facility's protocol for the residents with a Stage 3 pressure injury to have a LAL mattress. Residents Affected - Few 555536 Page 2 of 2