Health inspection·December 14, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some * 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. These failures posed the risk for the transmission of disease-causing microorganisms. Findings: According to CDC, Coronavirus 2019 (COVID-19) Factsheet, to use PPE when caring for patients with confirmed or suspected Covid-19. The factsheet also showed the following: - The preferred PPE to use are: N95 or higher respirator, face shield or goggles, one pair of clean, non-sterile gloves, and isolation gown. According to CDC, for droplet precautions, everyone must clean their hands, including before entering and when leaving the room. Make sure the eyes, nose and mouth are fully covered before room entry, and remove face protection before room exit. According to CDC, for contact precautions, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of the facility ' s P&P titled Coronavirus Disease (Covid-19) – Identification and Management of Ill Residents revised 9/2022, under the Personal Protective Equipment section, showed the staff who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection will adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, Page 1 of 3 555295 555295 12/14/2023 Regents Point - Windcrest 19191 Harvard Avenue Irvine, CA 92612

F 0880 Level of Harm - Minimal harm or potential for actual harm gown, gloves, and eye protection (such as goggles or face shield that covers the front and sides of the face). Review of the facility census form dated 11/28/23, showed there were 16 residents who were actively on isolation for Covid-19 in Nursing Station 2. Residents Affected - Some Review of the staffing schedule dated 11/29/23, showed LVN 2 was assigned to Nursing Station 2 where Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P were. Further review of the staffing schedule dated 11/29/23, showed CNA 2 was assigned to Rooms A, B, C, and D. 1.a. On 11/29/23 at 1218 hours, the CDC droplet and contact precautions signs were observed posted outside of Room B, alerting everyone to don a mask, face shield, gloves, and gown prior to entering the room. An isolation cart containing gloves and gown was observed near the entrance door. CNA 2 was observed inside the room and assisting Resident E with the lunch tray. CNA 2 was observed wearing N95, and her face shield was observed worn on top of her head and not fully covering her face. CNA 2 was not observed wearing gown nor gloves. Then CNA 2 was observed exiting the room and using the alcohol-based hand rub. b. On 11/29/23 at 1222 hours, CNA 2 was observed entering Room B and went to Resident F to deliver the resident ' s lunch tray. CNA 2 was observed wearing N95, and her face shield was observed on top of her head and not fully covering her face. CNA 2 was observed not wearing gown nor gloves. Then, CNA 2 was observed exiting the room and using the alcohol-based hand rub. c. On 11/29/22 at 1224 hours, the CDC droplet and contact precautions signs were observed posted outside of Room A, alerting everyone to don a mask, face shield, gloves, and gown prior to entering the room. An isolation cart containing gloves and gown was observed near the entrance door. CNA 2 was observed entering Room A, with a lunch tray. CNA 2 was observed wearing the N95 and face shield. CNA 2 was observed not wearing gown nor gloves. Then, CNA 2 was observed exiting the room and using the alcohol-based hand rub. On 11/29/22 at 1225 hours, CNA 2 was observed entering Room A again. CNA 2 was observed wearing N95 and face shield. CNA 2 was observed not wearing gown nor gloves. Then, CNA 2 was observed exiting the room and using the alcohol-based hand rub. d. On 11/29/22 at 1228 hours, the CDC droplet and contact precautions signs were observed posted outside of Room C, alerting everyone to don a mask, face shield, gloves, and gown prior to entering the room. An isolation cart containing gloves and gown was observed near the entrance door. CNA 2 was observed entering Room C. CNA 2 was observed wearing the N95 and face shield. CNA 2 was observed not wearing gown nor gloves. e. On 11/29/22 at 1230 hours, the CDC droplet and contact precautions signs were observed posted outside of Room D, alerting everyone to don a mask, face shield, gloves, and gown prior to entering the room. An isolation cart containing gloves and gown was observed near the entrance door. CNA 2 was observed entering Room D. CNA 2 was observed wearing the N95 and face shield. CNA 2 was observed not wearing gown nor gloves. On 11/29/22 at 1310 hours, an interview was conducted with CNA 2. CNA 2 was observed wearing N95 555295 Page 2 of 3 555295 12/14/2023 Regents Point - Windcrest 19191 Harvard Avenue Irvine, CA 92612

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some below her nose and face shield. CNA 2 verified the above findings. CNA 2 verified she was wearing the N95 mask below her nose. CNA 2 stated she was assigned to eight residents who were on Covid-19 isolation rooms. CNA 2 verified there were droplet and contact precautions posted by the residents ' doors. CNA 2 verified she only wore the N95 and face shieldwhen entering the residents ' rooms on Covid-19 isolation. CNA 2 stated she only wore the N95 and face shield because she only delivered the residents ' lunch tray and did not touch the residents. 2. On 11/29/22 at 1229 hours, the CDC droplet and contact precautions signs were observed posted outside of Room C, alerting everyone to don a mask, face shield, gloves, and gown prior to entering the room. An isolation cart containing gloves and gown was observed near the entrance door. The Housekeeper was observed coming out of Room C wearing the N95, face shield and gown. The Housekeeper was observed getting a broom from the housekeeping cart which was parked in the hallway, across the residents ' room. On 11/29/22 at 1232 hours, the Housekeeper was observed coming out of Room C wearing N95, face shieldand gown. The Housekeeper was observed doffing the isolation gown in the hallway, in front of the housekeeping cart. On 11/29/33 at 1233 hours, an interview was conducted with the Housekeeper. The Housekeeper verified the above findings. The Housekeeper stated she wore and doffed the isolation gown outside the room because she saw the CNAs doing it and she thought that was okay to do. 3. On 11/29/23 at 1321 hours, an observation for the residents in Nursing Station 2 and concurrent interview was conducted with LVN 2. LVN 2 verified there were 16 residents in Nursing Station 2 who were on isolation for Covid-19. LVN 2 verified the contact and droplet precaution signs were posted outside the rooms of Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P. When asked what PPE should be worn when providing care to the residents who were on isolation for Covid-19, LVN 2 stated the staff should wear the N95, gloves, and gown. When asked about wearing a face shield, LVN 2 answered, I think so. But I do not have one. We do not have face shields in the facility. When asked what PPE she used when administering medications and providing care to the residents on isolation for Covid-19, LVN 2 answered, I have been passing medications to the residents without a face shield. LVN 2 stated the staff should wear the full PPE or N95, face shield, gloves, and gown, even when they were just going inside the room. On 11/29/23 at 1352 hours, an observation and concurrent interview was conducted with the IP. The IP verified the above findings. The IP stated the staff should have worn the N95, face shield, gown and gloves when entering the rooms of residents on Covid-19 isolation. When asked to show the face shields to be used by the staff, the IP was able to show the face shieldsavailable in the facility. When asked when the staff should remove the PPE, the IP stated the staff should remove the PPE including the gown before exiting the Covid-19 isolation room. 555295 Page 3 of 3