Regents Point - Windcrest

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the residents received adequate fall prevention interventions identified for three of three residents reviewed for falls (Residents 9, 40, and 52). * Resident 9 had unwitnessed fall incidents on 2/24, 3/13, and 3/17/26. Resident 9's post-fall neurological assessments were incomplete and inaccurate, and the facility failed to document a COC form. In addition, the facility failed to ensure Resident 9 was provided appropriate care after his fall incident on 2/24/26. * The facility failed to implement the floor mattress as ordered by the physician as a fall risk precaution for Resident 40. * The facility failed to conduct a post fall assessments when Resident 52 had a fall on 12/1/25. [...]

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, facility document review, and the California Code of Regulations, the facility failed to ensure a staff member was onsite who could provide respiratory services to the residents, in accordance with the residents' plan of care. * For the past year, during the night shift on Fridays and Saturdays, the facility failed to ensure a staff member was on site at the facility, who could provide respiratory services to the residents with oxygen titration orders. This failure had the potential to result in negative health outcomes for the residents. Review of California Code of Regulations, title 16, section 1399.365, showed the respiratory care services LVNs may perform in the long-term care setting. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were maintained in sanitary condition and had smooth, clean surfaces. * The facility failed to ensure the heavy-duty blenders used for puree preparation were air dried prior to storage. * The facility failed to maintain the hood over the stove in a clean and sanitary condition. * The facility failed to ensure the kitchen utensils had smooth, cleanable surfaces and were maintained in good repair. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the hair and/or beard restraint was worn appropriately by the dietary staff. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 36) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 36's lorazepam (antianxiety medication) medication was administered according to the physician's orders. This failure had the potential risk for the resident to experience adverse effects associated with the psychotropic medication.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents and/ or responsible party as well as the Ombudsman about the transfer, discharge, and bed-hold information upon the residents transfer to an acute care hospital for three of five residents reviewed for acute care hospital transfer (Residents 5, 9, and 52). * The facility failed to ensure the Ombudsman was notified of Resident 5's acute care hospital transfer on 9/5/25, and 5/13/26. In addition, the facility failed to ensure Resident 5's responsible party received a written bed-hold notice for Resident 5's 5/13/26, acute care hospital transfer. * The facility failed to ensure the Ombudsman was notified of Resident 9's acute care hospital transfer on 3/13/26, and 3/17/26. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for one of 13 final sampled resident (Residents 6). * The facility failed to develop a care plan to address Resident 6's dementia diagnosis and the use of alternate pressure relieving mattress for skin management. This failure posed the risk for the resident not receiving the necessary care and services to improve or maintain their highest level of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pressure injury care and services for one of two sampled residents (Resident 11) reviewed for pressure injuries. * The facility failed to ensure Resident 11's pressure relieving mattress setting was consistent with the resident's weight and comfort. This failure had the potential for the resident to not benefit from the therapy provided by the pressure relieving mattress.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for the use of the indwelling urinary catheter to one of five sampled residents (Resident 6) reviewed for indwelling urinary catheter use. * Resident 6 had a physician's order for indwelling urinary catheter; however, the physician's order did not include the diagnosis or clinical indication to justify the need for the continued use of the indwelling urinary catheter. This failure had the potential for Resident 6 to continue using an indwelling urinary catheter without a medically necessary reason.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide appropriate care for the peripheral and central line access devices consistent with professional standards of practice for two of two residents reviewed for parenteral IV fluids (Resident 56 and nonsampled Resident 24). * RN 1 failed to assess Resident 24's PICC line for patency by aspirating for blood return prior to administering intravenous medication. * The facility failed to ensure the peripheral IV line dressing for Resident 56 was labeled and dated. These failures had the potential to delay identification of a central line associated complication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 13 final sampled residents (Residents 3, 11, and 13) reviewed for oxygen therapy. * The facility failed to ensure signage for oxygen use was placed in Resident 3 and Resident 13's door. * The facility failed to ensure the physician's order for the PRN oxygen therapy for Resident 11 was transcribed to the facility's order from the hospice. In addition, the facility failed to ensure Resident 11's oxygen signage was posted on the door. These failures had the potential for the residents to not receive the appropriate care and may negatively impact on the residents' medical conditions.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage.* The facility failed to ensure expired medication was removed from Medication Cart A. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the following: * Federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). * The Director of Dining was competent in managing the day-to-day functions of the food and nutrition department. These failures to employ staff with the federal and state mandated qualifications to manage the food and nutrition department, the competencies to effectively and competently run the day to day operations of the food and nutrition department, and to effectively implement departmental processes in accordance with standards of practice, had the potential to jeopardize the health and well-being of the 43 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests or rodents that can carry diseases.

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to ensure the medical record was complete and accurately maintained, for two of 13 final sampled residents (Residents 3 and 56).*The facility failed to ensure Resident 3's Arbitration Agreement contained the date signatures were obtained for the facility representative and Resident 3's representative.*The facility failed to ensure Resident 3's POLST contained the physician's name and phone number. *Resident 56's POLST failed to show if the resident had formulated an advance directive. These failures had the potential for the residents' care needs not being met as the medical record was incomplete.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 13 final sampled residents (Resident 11). * The facility failed to ensure the hospice visit calendar, hospice skilled nurse visit notes, and physician's certification for hospice benefits were available and included in Resident 11's medical records. This failure posed the risk of delay in communication between the hospice provider and facility which may affect resident care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control program to prevent the development and transmission of infections. * RN 1 failed to wear required personal protective equipment (PPE) while providing central line care for Resident 24, who was on enhanced barrier precautions (EBP). In addition, RN 1 failed to perform hand hygiene during the medication administration. * LVN 1 failed to perform hand hygiene during the medication administration for Residents 6 and 34. * LVN 2 failed to perform hand hygiene during the medication administration for Resident 5. * The facility failed to ensure clean linens and towels were stored in a manner that protected them from potential contamination in the laundry storage area. [...]

Inspectors wrote5. On 5/12/25 at 1036 hours, during the initial tour of the facility, Resident 15 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 5/13/25 at 0923 hours, Resident 15 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 15 was initiated on 5/12/25. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Order Summary Report dated 5/13/25, failed to show a physician's order for the use of bilateral half side rails in bed. Review of Resident 15's H&P examination dated 4/11/24, showed Resident 15 had a diagnosis of failure to thrive, T12 compression fracture (a break in the twelfth thoracic vertebra (T12) located in the mid-back), and osteoporosis (a disease that weakens bones, making them more likely to break). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in appetizing temperatures: * The temperature was not maintained at the acceptable range for cold beverages. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blenders used for puree preparation were dried and clean prior to storing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for nine of 13 final sampled residents (Residents 1, 2, 12, 15, 18, 19, 34, 40, and 397) and one nonsampled resident (Resident 16). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide written information regarding the right to formulate advance healthcare directives for one of 13 final sampled residents (Resident 19) and one nonsampled resident (Resident 298) reviewed for formulation of advance healthcare directives. This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Resident 34) was free from accident hazards. The facility failed to implement floor mattress as ordered by the physician as a fall risk precaution for Resident 34. This failure had the potential for serious injury to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one nonsampled resident (Resident 299). * The facility failed to ensure the PICC line catheter measurements were obtained and documented. In addition, the facility failed to ensure the PICC line plan of care included the measurements of the length of the external catheter and arm circumference. These failures had the potential to delay the identification of IV catheter related complications for Resident 299.

Inspectors wrote2. Review of the facility's P&P titled CPAP/BiPAP Support revised 3/2015 showed to review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure for the machine. Review and follow manufacturer's instruction for CPAP machine setup and oxygen delivery. Under the general guidelines for cleaning showed the following: - Machine cleaning: to wipe the machine with soapy water and rinse at least once a week and as needed. - Humidifier (if used): use clean, distilled water only in the humidifier chamber; to clean the humidifier weekly and air dry; and to disinfect using vinegar-water solution (1:3) in the clean humidifier. To soak for 30 minutes and rinse thoroughly. - Filter cleaning: to rinse the washable filter under running water once a week to remove dust and debris. - Mask and nasal pillows: to wipe with isopropyl alcohol daily after use. [...]

Inspectors wrote2. Review of the facility's P&P titled Medication Administration Subcutaneous dated 2007 showed the licensed nurses to administer medications via the subcutaneous route in a safe, accurate and effective manner. The procedures included the following: - To check the last injection sites and select a new appropriate site for injection. - To document the injection on the MAR along with the site. Medical record review for Resident 597 was initiated on 5/13/25. Resident 597 was admitted to the facility on [DATE]. On 5/14/25 at 1410 hours, an observation and concurrent interview was conducted with Resident 597. Resident 597 was in his wheelchair awake with bluish to greenish discoloration on the posterior right upper arm. Resident 597 stated the nurse gave his injection medication for blood clot on the back of his arm. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.45%. One of two licensed nurses (LVN 1) observed during the medication administration was found to have made errors. * LVN 1 failed to ensure metformin medication (antidiabetic) was administered to Resident 26 with meal as per the physician's orders. * LVN 1 failed to ensure Resident 697 received calcium citrate (supplement) on time following admission to the facility. These failures created the risk for the residents to have potential side effects or complications related to the medications.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;and 2. A contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wrote3. Review of the facility's P&P titled Bedpan/ Urinal Offering/ Removing dated 2/2018 showed store the bedpan or urinal as per facility policy. Review of the facility's P&P titled Handwashing/ Hygiene dated 8/2019 showed the use of an alcohol-based hand rub at least 62% alcohol or alternatively, soap (antimicrobial or non- antimicrobial) and water: after handling contaminated equipment. On 5/12/25 at 1242 hours, an observation in Resident 597's room and concurrent interview was conducted with CNA 5. Resident 597's urinal containing urine was observed on top of the overbed table near uncovered cups of water and cranberry juice. CNA 5 entered the room, put on gloves, removed the urinal, and discarded the urine to the toilet, rinsed the urinal, and placed the urinal back to Resident 597's overbed table near the uncovered cups of water and cranberry juice. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the dignity was maintained for one nonsampled resident (Resident 298) reviewed for urinary catheter care. * The facility failed to ensure the Resident 298's urinary catheter drainage bag was covered. This failure created the potential to affect the residents' well-being.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to ensure the medical record for one of 13 final sampled residents (Resident 298) was complete and accurate. This failure had the potential for Resident 298's care needs not being met as the medical record was inaccurate.

Inspectors wroteBased on interview and medical record review, the facility failed to monitor the resident's psychosocial wellness as per the care plan interventions for one of two sampled residents (Resident 1) after the allegation of the financial abuse. This failure had the potential to negatively impact Resident 1's mental and emotional well-being.

Inspectors wroteBased on record reviews, interviews, and document review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 (Resident #3 and Resident #34) of 12 sampled residents. Specifically, the facility incorrectly coded Resident #3 as not being considered by the state level I preadmission screening and resident review (PASARR) process to have a serious mental illness and Resident #34 as not receiving hospice care.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed after 1 (Resident #43) of 2 sampled residents reviewed for PASARR received a newly evident possible or serious medical illness.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure staff followed the physician's order to notify the physician when a resident's blood glucose level was above 300 milligrams per deciliter (mg/dL) and failed to hold a medication when the resident's systolic blood pressure (SBP) was greater than 140 milligrams of mercy (mmHg) for 1 (Resident #107) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure staff changed their gloves during the provision of catheter care for 1 (Resident #33) of 2 sampled residents reviewed for urinary catheters. The facility also failed to ensure staff disinfected a glucometer after use for 2 (Resident #16 and Resident #110) of 6 residents observed for medication administration.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a pneumococcal vaccine was administered once consent was received for 1 (Resident #25) of 5 sampled residents reviewed for immunizations.

Inspectors wroteBased on observation, interview, facility P&P review, and medical record review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections for 16 nonsampled residents on Station 2. * The facility failed to ensure the CNA followed the contact precautions to wear not only N95 and face shield but also gown and gloves before entering the Covid-19 isolation rooms. * The facility failed to ensure the Housekeeper followed the contact precautions for Covid-19 isolation room regarding the use and disposal of a gown. * The facility failed to ensure the licensed nurse followed the contact precautions to wear not only N95, gown, and gloves, but also face shield when passing the medications to the residents who were on Covid-19 isolation in Station 2. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided the necessary care and services after a fall. * Resident 1 fell while the resident was being transferred by two staff members from the shower chair to the bed. The nursing staff did not conduct a post fall assessment and monitor the resident for any change in condition after the fall. This failure had the potential for Resident 1 not receiving appropriate care in a timely manner.