Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555295
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
555295
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regents Point - Windcrest
19191 Harvard Avenue
Irvine, CA 92612
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 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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555295
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
555295
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regents Point - Windcrest
19191 Harvard Avenue
Irvine, CA 92612
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555295
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 14, 2023 survey of REGENTS POINT - WINDCREST?
This was a inspection survey of REGENTS POINT - WINDCREST on December 14, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at REGENTS POINT - WINDCREST on December 14, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.