Park Regency Care Center: Pressure Injury Care Failure - CA
The inspection, completed August 12, 2025, was triggered by a complaint. What inspectors found was straightforward: Resident 3 had a Stage 3 pressure injury upon admission and was placed without a low air loss mattress, a type of pressure-redistributing surface used to protect compromised skin from worsening. There was no physician's order for one. There was no mattress.
A licensed vocational nurse identified in the report as LVN 1 confirmed both facts. The resident had no low air loss mattress when admitted. No doctor had ordered one. And then LVN 1 said something that made the gap plain: the resident should have had one, because a Stage 3 pressure injury triggered the facility's own protocol requiring it.
Stage 3 pressure injuries reach through the full thickness of skin into the tissue below. They are not superficial. They are wounds that have already progressed through two earlier stages, and they carry real risk of deepening further if the pressure that caused them continues. A low air loss mattress works by continuously redistributing pressure across the body's surface, reducing the sustained force on vulnerable areas that allows wounds like this to form and grow.
The facility knew this. That was the point LVN 1 was making, and it was the same point a registered nurse, identified as RN 1, made separately. Stage 3 pressure injury, RN 1 said, meant a low air loss mattress. That was protocol.
Protocol and practice were not the same thing for Resident 3.
The violation was cited under F0686, which covers the care of residents with pressure injuries, and was tagged at a level of minimal harm or potential for actual harm. A small number of residents were identified as affected.
What the report does not contain is any explanation for how a resident with a documented Stage 3 wound moved through the admission process without the mattress protocol being activated. The nurses who spoke with inspectors did not describe a breakdown in communication, a shortage of equipment, or a competing clinical judgment. They described a protocol that existed and was not followed.
That absence of explanation is its own kind of finding. The facility had a rule. The nurses knew the rule. The rule applied to this resident. And when inspectors arrived and asked, the staff confirmed all of it, including the part where the rule wasn't followed.
Park Regency Care Center is a skilled nursing facility in La Habra, in Los Angeles County. The inspection was a complaint survey, meaning someone, whether a resident, a family member, or another party, raised a concern that prompted regulators to investigate.
The inspection report does not describe the current condition of Resident 3's wound, whether it worsened during the period without the appropriate mattress, or when, if ever, the low air loss mattress was provided. It records what was missing on the day inspectors looked.
For a resident already living with a wound that had eaten through the full thickness of skin, the missing mattress was not a paperwork problem. It was the difference between a care environment designed to stop further harm and one that wasn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Regency Care Center from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 24, 2026 · Our methodology
PARK REGENCY CARE CENTER in LA HABRA, CA was cited for violations during a health inspection on August 12, 2025.
The inspection, completed August 12, 2025, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.