Inspection Reports for
Regents Point
19191 Harvard Ave, Irvine, CA 92612, CA, 92612
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
82% occupied
Based on a February 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 327
Capacity: 399
Deficiencies: 0
Date: Feb 3, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on June 6, 2024, regarding residents not being evaluated for proper medical care and not receiving hygiene care.
Complaint Details
The complaint alleged that residents were not evaluated for proper medical care and were not receiving hygiene care. The investigation included interviews with residents and staff, review of resident rosters, and observation. The allegations were unsubstantiated due to conflicting information and lack of preponderance of evidence.
Findings
The investigation found conflicting information with most interviewed residents and staff denying the allegations. There was insufficient evidence to prove or refute the complaints, resulting in the allegations being deemed unsubstantiated. No citations were issued during the visit.
Report Facts
Capacity: 399
Census: 327
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Forney | Administrator | Facility administrator present during investigation |
| Sheila Weathers | Nurse Manager | Met with investigator and provided information |
| Ashley Croslin | Wellness Director | Met with investigator and provided information |
Inspection Report
Complaint Investigation
Census: 327
Capacity: 399
Deficiencies: 0
Date: Feb 3, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on June 6, 2024, regarding residents not being evaluated for proper medical care and not receiving hygiene care.
Complaint Details
The complaint alleged residents were not evaluated for proper medical care and were not receiving hygiene care. The investigation included interviews with residents and staff, review of resident rosters, and observation. The allegations were found unsubstantiated due to conflicting information and lack of preponderance of evidence.
Findings
The investigation found conflicting information with most interviewed residents and staff denying the allegations. There was insufficient evidence to prove or refute the complaints, resulting in the allegations being deemed unsubstantiated. No citations were issued during the visit.
Report Facts
Facility Capacity: 399
Resident Census: 327
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Forney | Administrator | Facility administrator present during the investigation |
| Sheila Weathers | Nurse Manager | Met with investigator and provided information during the investigation |
| Ashley Croslin | Wellness Director | Met with investigator and provided information during the investigation |
Inspection Report
Annual Inspection
Census: 326
Capacity: 399
Deficiencies: 0
Date: Jan 21, 2026
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst William Vanegas to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be clean, well-maintained, and compliant with all applicable regulations. No deficiencies were cited during the inspection. All safety equipment, emergency supplies, and resident accommodations met required standards.
Report Facts
Staff files reviewed: 10
Resident files reviewed: 10
Fire extinguisher count: All fire extinguishers were fully charged (exact count not stated)
Emergency drill date: Dec 21, 2025
Smoke and carbon monoxide detector test date: Dec 12, 2025
Hot water temperature range: Measured from 116.2 to 117.6 degrees Fahrenheit
Non-ambulatory capacity: 60
Hospice waiver capacity: 12
Resident census by care type: 285 independent living, 38 assisted living, 6 memory care
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director / Administrator | Present during inspection and assisted Licensing Program Analyst |
| Ashley Croslin | Director of Wellness | Participated in exit interview |
| William Vanegas | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 378
Capacity: 399
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report regarding a resident fall received by the Department on 2025-11-14.
Complaint Details
The visit was triggered by a complaint incident report about a resident fall. The fall was substantiated as accidental and not due to staff neglect.
Findings
The resident sustained an accidental fall resulting in an ankle fracture, with no evidence of staff neglect. No health and safety concerns were observed and no citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Goldman | Nurse Manager | Met during the inspection and involved in the exit interview. |
| Sheila Weathers | Nurse Manager | Met during the inspection and involved in the exit interview. |
| Celine Rodriguez | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sheila Santos | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 378
Capacity: 399
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report regarding a resident fall that occurred on 2025-11-10.
Complaint Details
The visit was triggered by a complaint/incident report about a resident fall. The fall was substantiated as accidental and not due to staff neglect.
Findings
The resident sustained an accidental fall resulting in an ankle fracture, with no evidence of staff neglect. No health or safety concerns were observed and no citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Goldman | Nurse Manager | Met during visit and involved in exit interview. |
| Sheila Weathers | Nurse Manager | Met during visit and involved in exit interview. |
| Celine Rodriguez | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sheila Santos | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Census: 280
Capacity: 399
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The visit was an unannounced case management inspection to follow up on an incident report received regarding a resident fall on 2025-10-03.
Complaint Details
The visit was triggered by a complaint incident report of a resident fall resulting in a knee fracture. The complaint was investigated and found no violations or hazards contributing to the fall.
Findings
The Licensing Program Analyst observed that the floor where the resident fell was flat and free of hazards. Video footage showed the resident tripped on their own feet. The resident was recovering and receiving physical therapy. No health or safety concerns were observed and no citations were issued.
Report Facts
Incident date: Oct 3, 2025
Report received date: Oct 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Croslin | Facility Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Celine Rodriguez | Licensing Program Analyst | Conducted the unannounced case management visit |
| Melinda M Forney | Administrator/Director | Named as facility administrator/director in report header |
Inspection Report
Complaint Investigation
Census: 280
Capacity: 399
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The visit was an unannounced case management follow-up on an incident report received regarding a resident fall on 2025-10-03.
Complaint Details
The visit was triggered by a complaint/incident report of a resident fall resulting in a knee fracture. The fall was found to be caused by the resident tripping on their own feet, not due to facility hazards. No substantiated violations were found.
Findings
The Licensing Program Analyst observed the incident video and the floor conditions, finding no hazards or obstructions. The resident was recovering well with physical therapy. No health and safety concerns or citations were noted during the visit.
Report Facts
Incident date: Oct 3, 2025
Report received date: Oct 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Croslin | Facility Administrator | Met with Licensing Program Analyst during inspection |
| Celine Rodriguez | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 399
Deficiencies: 2
Date: Jul 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on May 27, 2025, alleging that staff did not give resident medication as prescribed and did not keep the resident's authorized person informed about the resident's care.
Complaint Details
The complaint was substantiated. It was found that Resident 1 missed medication administration on more than 148 occasions and the responsible person was not properly informed about missed medications. The preponderance of evidence standard was met based on staff interviews and record reviews.
Findings
The investigation substantiated the allegations that Resident 1 missed medication administration on more than 148 instances and that the facility did not inform the responsible person when medication was not provided. Staff interviews and record reviews confirmed multiple missed medication doses and lack of notification to the responsible party.
Deficiencies (2)
Facility did not give medication according to the physician's directions.
Facility did not inform the responsible person for medication not administered to Resident 1.
Report Facts
Missed medication instances: 148
Facility capacity: 399
Resident census: 44
Plan of Correction due date: Jul 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 399
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-03-26 alleging multiple issues including resident falls due to lack of care, failure to obtain timely medical attention, double billing, and staff discouraging incident reporting.
Complaint Details
The complaint involved allegations that residents sustained multiple falls due to lack of care and supervision, failure to obtain timely medical attention for residents in distress, double billing of residents, and staff discouraging reporting of incidents. All allegations were found unsubstantiated based on record reviews and interviews.
Findings
The investigation found all allegations to be unsubstantiated. Records and interviews indicated appropriate staffing, timely medical care, no evidence of double billing, and that staff were reporting incidents as required.
Report Facts
Total licensed capacity: 399
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Melinda Forney | Administrator | Facility Administrator met during the investigation |
Inspection Report
Capacity: 399
Deficiencies: 0
Date: May 27, 2025
Visit Reason
An informal conference was conducted to discuss concerns regarding the facility policy and procedures.
Findings
The meeting resulted in agreements for the facility to provide updated policies on calling 911 by June 6, 2025, and an updated Plan of Operation by July 1, 2025. An exit interview was conducted and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director | Met with during the inspection and involved in the informal conference. |
| Sheila Santos | Licensing Program Manager | Present during the meeting and named as Licensing Program Manager. |
| Marina Stanic | Regional Manager | Present during the informal conference. |
| Brandon Lopez | Licensing Program Analyst | Present during the informal conference. |
| Ashley Croslin | Director of Wellness Programs | Present during the informal conference. |
| Melissa Goldman | Nurse Supervisor Residential Living | Present during the informal conference. |
| Sheila Weathers | Nurse Supervisor Assisted Living and Memory Support | Present during the informal conference. |
Inspection Report
Routine
Deficiencies: 14
Date: May 15, 2025
Visit Reason
Routine inspection of Regents Point - Windcrest nursing home to assess compliance with regulatory requirements including resident care, medication administration, infection control, and safety.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, incomplete advance directive documentation, failure to implement fall precautions, inadequate IV and respiratory care, improper oxygen administration, unsafe use of bed rails without orders or consent, medication administration errors, unsanitary kitchen conditions, incomplete facility assessment, incomplete medical records, infection control lapses, and incomplete entrapment assessments.
Deficiencies (14)
F 0557: The facility failed to ensure Resident 298's urinary catheter drainage bag was covered, compromising dignity and privacy.
F 0578: The facility failed to provide written information regarding advance directives to Residents 19 and 298, risking residents' healthcare decisions not being honored.
F 0689: The facility failed to implement a physician-ordered floor mattress for Resident 34, increasing fall risk.
F 0694: The facility failed to obtain and document PICC line catheter measurements and include them in the plan of care for Resident 299, risking delayed identification of complications.
F 0695: The facility failed to provide safe and appropriate respiratory care for Residents 19, 40, 297, and 397, including improper oxygen administration and lack of CPAP machine orders and care plans.
F 0700: The facility failed to obtain physician orders, informed consent, and complete assessments for the use of bilateral half side rails for multiple residents, risking entrapment and injury.
F 0755: The facility failed to provide pharmaceutical services meeting residents' needs, including medication reconciliation errors and failure to rotate injection sites for Resident 597.
F 0759: The facility failed to ensure medication error rates were below 5%, with errors including failure to administer metformin with meals and delayed calcium citrate administration.
F 0804: The facility failed to maintain cold beverage temperatures within safe limits, risking unpalatable food service.
F 0812: The facility failed to maintain sanitary kitchen conditions, including dirty utensils, damaged equipment, unclean cutting boards, and wet blenders, risking cross contamination and foodborne illness.
F 0838: The facility failed to include direct care staff and contingency staffing plans in the Facility Assessment, risking inadequate care during emergencies.
F 0842: The facility failed to maintain complete and accurate medical records for Resident 298, including incomplete urine output documentation.
F 0880: The facility failed to implement infection control practices, including improper storage of personal belongings with clean linen, failure of LVN 6 to perform hand hygiene during wound care, and CNA 5 handling a urinal near beverages without hand hygiene.
F 0909: The facility failed to accurately complete entrapment assessments for bed rails for multiple residents, omitting Zones 6 and 7, risking entrapment and injury.
Report Facts
Medication error rate: 6.45
Number of residents consuming kitchen food: 45
Temperature of cold beverages: 42.6
Temperature of cold beverages: 43.8
Temperature of cold beverages: 42.8
Temperature of cold beverages: 43.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Nurse | Administered anticoagulant injection without rotating sites; medication administration errors |
| RN 1 | Registered Nurse | Verified medication administration errors and PICC line care deficiencies |
| CNA 5 | Certified Nursing Assistant | Handled urinal near beverages without hand hygiene |
| LVN 5 | Licensed Nurse | Failed to perform hand hygiene during wound care treatment |
| DON | Director of Nursing | Verified multiple findings including infection control and medication administration |
| Administrator | Facility Administrator | Acknowledged multiple findings and facility assessment deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged incomplete entrapment assessments and bed safety inspections |
| Dietary Aide | Dietary Aide | Acknowledged unsanitary kitchen conditions and improper food equipment maintenance |
| LVN 3 | Licensed Nurse | Verified missing informed consent and entrapment assessments for side rails |
| LVN 6 | Licensed Nurse | Failed hand hygiene during wound care |
Inspection Report
Annual Inspection
Census: 318
Capacity: 399
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the Regents Point facility to assess compliance with regulations.
Findings
The facility was generally compliant with regulatory requirements, including safety equipment and food supply standards. However, deficiencies were cited related to hot water temperature exceeding the allowed maximum in seven of eight resident bathrooms and a resident missing six out of thirty-three prescribed medications.
Deficiencies (2)
Hot water temperature in seven out of eight resident bathrooms exceeded the maximum allowed temperature of 120 degrees Fahrenheit, posing a potential safety risk.
Resident one (R1) was missing six out of thirty-three prescribed medications, posing an immediate health, safety, and personal rights risk.
Report Facts
Hot water temperature measurements: 7
Prescribed medications missing: 6
Total prescribed medications for R1: 33
Census: 318
Total capacity: 399
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director | Met with Licensing Program Analysts during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted inspection and authored report |
| Nancy Guillen | Licensing Program Analyst | Conducted inspection |
| Sheila Santos | Licensing Program Manager | Supervisor named in report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 22, 2024
Visit Reason
The inspection was conducted following a complaint report received on 11/7/24 regarding alleged financial abuse of Resident 1 at the facility.
Complaint Details
The complaint investigation was substantiated based on findings that the facility did not follow care plan interventions to monitor Resident 1's psychosocial wellness after an allegation of financial abuse.
Findings
The facility failed to monitor Resident 1's psychosocial wellness as required by the care plan interventions for 72 hours after the allegation of financial abuse. Psychosocial monitoring notes were missing from social services staff on 11/7 and 11/8/24, and nursing progress notes were absent on 11/8/24.
Deficiencies (1)
F 0656: The facility failed to monitor Resident 1 for psychosocial effects for 72 hours after an allegation of financial abuse, as required by the care plan. Monitoring notes from nursing and social services staff were missing for specified dates.
Report Facts
Monitoring period: 72
Dates missing monitoring notes: 2
Date missing nursing progress note: 1
Inspection Report
Routine
Deficiencies: 5
Date: May 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, preadmission screening, medication administration, infection control, catheter care, and immunization policies at Regents Point - Windcrest nursing home.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for sampled residents, incomplete preadmission screening and resident review (PASARR) evaluations, failure to follow physician orders for medication administration, inadequate infection prevention practices including failure to disinfect glucometers and change gloves during catheter care, and failure to administer pneumococcal vaccine after consent was obtained.
Deficiencies (5)
F0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 residents, including incorrect coding of PASARR status and hospice care.
F0644: The facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for a resident with a newly evident serious medical illness.
F0684: The facility failed to follow physician orders by administering medication when systolic blood pressure exceeded the limit and failing to notify the physician of elevated blood glucose levels for a resident.
F0880: The facility failed to ensure staff disinfected glucometers after each use and changed gloves during catheter care, risking cross-contamination.
F0883: The facility failed to administer a pneumococcal vaccine to a resident after consent was received.
Report Facts
Residents sampled for MDS accuracy: 12
Residents sampled for PASARR evaluation: 2
Residents sampled for unnecessary medications: 5
Residents observed for medication administration: 6
Residents sampled for immunizations: 5
Blood glucose level: 347
Systolic blood pressure: 148
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse #1 | Licensed Vocational Nurse | Documented medication administration and blood glucose levels for Resident #107; admitted not notifying physician |
| Registered Nurse #7 | Registered Nurse | Observed not disinfecting glucometer after use |
| Certified Nurse Assistant #4 | Certified Nurse Assistant | Observed not changing gloves during catheter care |
| Licensed Vocational Nurse #5 | Licensed Vocational Nurse and Infection Preventionist | Stated staff should change gloves and perform hand hygiene when moving from dirty to clean tasks |
| MDS Coordinator #2 | Interviewed regarding MDS accuracy and PASARR evaluations | |
| Director of Nursing | Director of Nursing | Interviewed regarding MDS accuracy, PASARR evaluations, medication administration, and infection control expectations |
| Administrator | Administrator | Interviewed regarding MDS accuracy, PASARR evaluations, medication administration, infection control, and immunization compliance |
| Medical Doctor | Medical Doctor | Interviewed regarding medication administration concerns for Resident #107 |
| Licensed Vocational Nurse #6 | Director of Staff Development/LVN | Interviewed regarding pneumococcal vaccine administration |
Inspection Report
Complaint Investigation
Census: 296
Capacity: 399
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2020-12-01 regarding allegations that a resident developed pressure injuries due to neglect and sustained an injury due to an unwitnessed fall.
Complaint Details
The complaint involved allegations that a resident developed pressure injuries due to neglect and sustained an injury due to an unwitnessed fall. The investigation was unsubstantiated, meaning there was insufficient evidence to prove the allegations.
Findings
The investigation found that based on medical records and staff interviews, the allegations were unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. No deficiencies were cited.
Report Facts
Capacity: 399
Census: 296
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sheila Weathers | Nurse Manager | Met with Licensing Program Analyst during the investigation |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 301
Capacity: 399
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
Licensing Program Analyst Claudia Gutierrez made an unannounced visit to conduct a Required/Annual Inspection of the Regents Point facility.
Findings
The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Observations included operable delayed egress, proper furnishings, safe water temperatures, secured medication rooms, and adequate emergency preparedness.
Report Facts
Residents in memory care: 7
Residents in assisted living: 36
Residents in independent living: 258
Water temperature range (F): 107.6-120.7
Fire extinguisher service date: Aug 3, 2023
Resident files reviewed: 15
Staff interviewed: 5
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director | Met with Licensing Program Analyst during inspection |
| Ashely Croslin | Director of Wellness | Met with Licensing Program Analyst during inspection |
| Melissa Goldman | Nurse Manager | Conducted tour of independent living |
| Reyna Medina | Health Service Coordinator | Conducted tour of independent living |
| Sheila Weathers | Nurse Manager | Conducted tour of assisted living and memory care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to implement proper infection prevention and control practices related to COVID-19 isolation precautions in the facility.
Complaint Details
The complaint investigation found substantiated failures in infection control practices related to PPE use by CNA, Housekeeper, and licensed nurse in COVID-19 isolation areas.
Findings
The facility failed to ensure staff consistently followed required contact and droplet precautions, including proper use of PPE such as gowns, gloves, and face shields when entering COVID-19 isolation rooms. These failures posed a risk for transmission of disease-causing microorganisms among residents.
Deficiencies (1)
F 0880: The facility failed to ensure the CNA wore gown and gloves in addition to N95 and face shield before entering COVID-19 isolation rooms. The Housekeeper improperly doffed isolation gowns outside the room. The licensed nurse did not wear a face shield when passing medications to residents in COVID-19 isolation.
Report Facts
Residents on COVID-19 isolation: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Observed and interviewed regarding improper PPE use in COVID-19 isolation rooms | |
| LVN 2 | Licensed Nurse | Interviewed and verified PPE use practices and resident assignments in COVID-19 isolation |
| Housekeeper | Observed and interviewed regarding gown use and doffing practices in COVID-19 isolation rooms | |
| IP | Infection Preventionist | Interviewed and verified PPE requirements and availability for COVID-19 isolation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate care and services to a resident after a fall.
Complaint Details
The complaint investigation found that Resident 1 fell on 8/21/23 during transfer by two staff members. The fall was not reported or documented until after an x-ray on 8/29/23 revealed a distal femur fracture. Staff interviews confirmed failure to use gait belts and delayed reporting. The Director of Nursing acknowledged the failure to report and document the fall timely.
Findings
The facility failed to ensure that Resident 1 received a post-fall assessment and monitoring after a fall on 8/21/23. The fall was not reported or documented timely, and staff did not use a gait belt during the transfer, contrary to facility instructions.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences after Resident 1 fell during transfer. There was no documented post-fall assessment or monitoring for changes in condition after the fall on 8/21/23.
Report Facts
Date of fall: Aug 21, 2023
Date of x-ray: Aug 29, 2023
Date of survey completion: Sep 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 1 | Interviewed regarding Resident 1's fall and transfer procedures | |
| CNA 1 | Interviewed regarding Resident 1's fall and transfer procedures | |
| LVN 2 | Interviewed about documentation and reporting of Resident 1's fall | |
| DON | Director of Nursing | Acknowledged failure to report and document Resident 1's fall timely |
Inspection Report
Complaint Investigation
Census: 256
Capacity: 399
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-04-06 regarding staffing levels, laundry misplacement, facility cleanliness, medical device sanitation, and infection control compliance.
Complaint Details
The complaint investigation was unannounced and involved 11 interviews with residents and staff. The allegations included lack of staffing, misplacement of laundry, inadequate cleaning and disinfecting, unclean medical devices, and failure to follow infection control requirements. All allegations except laundry misplacement were found to be unsubstantiated or unfounded. The laundry misplacement allegation was unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found that the allegations of lack of staffing, facility cleanliness, medical device sanitation, and infection control noncompliance were unsubstantiated or unfounded based on interviews, observations, and document reviews. The allegation regarding misplacement of resident laundry was deemed unsubstantiated due to insufficient evidence to prove or refute the claim.
Report Facts
Number of interviews conducted: 11
Facility capacity: 399
Facility census: 256
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ashley Croslin | Health and Wellness Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Melinda M Forney | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 343
Capacity: 399
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint alleging that a resident sustained an unwitnessed fall due to lack of supervision while in care.
Complaint Details
The complaint alleged that a resident sustained an unwitnessed fall due to lack of supervision. The investigation included interviews with staff and residents, review of incident reports and medical documents, and observation. All evidence and interviews did not corroborate the allegation, and the complaint was determined to be unfounded.
Findings
After conducting interviews, reviewing records, and touring the facility, the complaint was found to be unfounded as the allegation was false or without reasonable basis. No citations were issued during the visit.
Report Facts
Residents on hospice: 5
Interviews conducted: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Ashley Croslin | Health and Wellness Director / Facility Administrator | Met with investigator during visit |
| Sheila Weathers | Nurse Manager | Met with investigator during visit |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 27, 2023
Visit Reason
Routine inspection of Regents Point - Windcrest nursing home to assess compliance with regulatory requirements including resident care, medication administration, infection control, and facility safety.
Findings
The inspection identified multiple deficiencies including failure to validate advance directives, failure to notify physician and responsible party of significant weight loss, failure to revise care plans accordingly, incomplete post-fall neurological assessments, inaccurate insulin dosing practices, use of personal unapproved vital sign equipment, infection control lapses in disinfecting equipment, improper food storage and labeling, and exposure of confidential resident information.
Deficiencies (12)
F578: The facility failed to ensure a valid advance directive was in the medical record for Resident 28, missing required witness signatures or notarization.
F580: The facility failed to notify Resident 13's physician and responsible party of significant and continued weight loss, risking delayed care.
F657: The facility failed to revise Resident 13's care plan to reflect current significant unplanned weight loss, risking inappropriate care.
F689: The facility failed to complete timely post-fall neurological assessments for Resident 27, risking delayed detection of neurological changes.
F692: Resident 13 experienced significant unplanned weight loss without appropriate interventions, physician and responsible party notification, or care plan updates.
F695: Resident 39 was administered insulin using a 100 unit/ml syringe without proper markings for 5 units, risking inaccurate dosing.
F698: Resident 10 received oxygen therapy without a physician's order for oxygen administration.
F758: Residents 5 and 13 received unnecessary medications; Resident 13 received an ineffective antibiotic and Resident 5 was prescribed Seroquel without documented rationale.
F812: The facility failed to maintain sanitary kitchen conditions including marred cutting boards, dirty pans, unlabeled and expired food items.
F842: Confidential resident rosters were accessible to the public in the survey results binder, risking breach of resident privacy.
F880: The facility failed to follow infection control guidelines; staff used inappropriate wipes to disinfect vital sign equipment and failed to disinfect properly between residents.
F908: Staff used personal vital sign equipment not maintained or approved by the facility, risking inaccurate vital sign measurements.
Report Facts
Weight loss: 9.2
Weight loss: 8.8
Weight loss: 13.1
Weight loss: 19.5
Insulin dose: 5
Oxygen flow rate: 2
Expired food items: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Used personal vital sign equipment and improperly disinfected equipment |
| LVN 1 | Licensed Vocational Nurse | Used personal blood pressure device and improperly disinfected equipment |
| DON | Director of Nursing | Verified deficiencies and acknowledged findings |
| RD | Registered Dietitian | Reviewed Resident 13's weight loss and care plan deficiencies |
| Pharmacy Consultant | Pharmacist | Advised on insulin syringe use and medication safety |
| Psychiatry Consultant | Psychiatrist | Ordered Seroquel for Resident 5 without documented rationale |
Inspection Report
Census: 251
Capacity: 399
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
Unannounced case management visit to follow up on a report of a resident claiming her jewelry was stolen.
Findings
No deficiencies were noted during the visit and no citations were issued. The resident declined to file a police report after initially claiming jewelry was stolen.
Report Facts
Residents on hospice: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Goldman | Licensed Vocational Nurse/Nurse Manager | Interviewed during the visit and provided information about the resident's jewelry incident |
| Ashley Croslin | Director of Wellness | Reported the incident of the resident claiming jewelry was stolen |
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Census: 290
Capacity: 399
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report for resident #1 that occurred on 2022-09-29.
Findings
No deficiencies were noted during the visit and no citations were issued. The facility was toured and resident #1's file and room were reviewed, including an interview with the resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Croslin | Director of Wellness | Met with during the visit and participated in exit interview. |
| Melissa Goldman | Nurse Manager | Accompanied the Licensing Program Analyst on the facility tour and participated in exit interview. |
| Melinda Forney | Executive Director | Met with during the visit and participated in exit interview. |
Inspection Report
Census: 287
Capacity: 399
Deficiencies: 0
Date: Mar 7, 2022
Visit Reason
Unannounced case management visit to follow up on an incident report submitted regarding missing medication.
Findings
The facility reported a missing discontinued medication with a cash value of $19.00. The facility investigated, involved police, interviewed staff, and changed medication destruction procedures. No further investigation was needed.
Report Facts
Cash value of missing medication: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director | Met with Licensing Program Analyst during visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 287
Capacity: 399
Deficiencies: 0
Date: Mar 7, 2022
Visit Reason
The visit was an unannounced Required 1 Year inspection to evaluate the facility's compliance with licensing regulations.
Findings
No deficiencies were noted during the visit. The facility appeared clean, sanitary, and well maintained with all required elements in place. Residents appeared happy and well cared for, and COVID-19 mitigation plans were in place and approved.
Report Facts
Residents in memory care unit: 7
Residents in assisted living: 37
Residents in independent living: 243
Non-ambulatory residents: 60
Residents on hospice care: 4
Hospice waiver capacity: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Executive Director | Met during inspection and holds administrator certificate expiring 07/22/2023 |
| Ashley Croslin | Director of Wellness | Present during inspection and met with Licensing Program Analyst |
| Sheila Weathers | Nurse Manager | Present during inspection |
Inspection Report
Census: 289
Capacity: 399
Deficiencies: 0
Date: Jun 15, 2021
Visit Reason
Unannounced case management visit to follow up on multiple incident reports received by Community Care Licensing (CCL).
Findings
Multiple incidents involving residents were reviewed, including medical emergencies and financial abuse concerns. The Licensing Program Analyst toured the facility and observed visitation areas. No deficiencies were noted during the visit.
Report Facts
Incident report dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Forney | Administrator / Executive Director | Met with Licensing Program Analyst during visit |
| Ashley Croslin | Director of Wellness Programs | Met with Licensing Program Analyst during visit |
| Melissa Diaz | Nurse Manager | Present during visit |
| Cindy Fuentes | Nurse Manager | Present during visit |
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit |
| Alisa Ortiz | Licensing Program Manager | Named in report |
Viewing
Loading inspection reports...
