Bay Crest Care Center

During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment.

Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.

Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and homelike environment to emphasize sufficient general lighting in resident-use areas and task lighting as needed.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition, dated

misappropriation of resident property, and exploitation for all residents.

Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a patient or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

During a review of the facility's P&P titled, Dignity, dated February 2021, indicated, Residents are treated with dignity and respect at all times.

Staff speak respectfully to residents at all times.

During a review of the facility's P&P titled, Resident Rights, dated 12/2021, indicated, Employees shall treat all residents with kindness, respect, and dignity.

Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including encephalopathy (brain damage or disease that affects how the brain functions, and dementia (a progressive state of decline in mental abilities).

During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 12/23/2024, the MDS indicated Resident 61 was severely cognitively (ability to think, understand, learn, and remember) impaired.

The MDS indicated Resident 61 required partial/moderate assistance (helper does less than half the effort) with eating, hygiene, and dressing.

During a review of Resident 61's History and Physical (H&P) dated 9/19/2024, the H&P indicated Resident 61 does not have the capacity to understand and make decisions.

During a concurrent observation and interview on 1/27/2025 at 10:46 a.m., with Certified Nurse Assistant (CNA) 8, CNA 8 stated Resident 61's bed was against the wall and the Resident 61 cannot get out easily.

During a concurrent interview and record review on 1/28/2025 at 2:59 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 61's bed was against the wall but was unsure why. LVN 4 stated a resident's bed against the wall is considered a restraint and should be addressed in the care plan. LVN 4 stated there was no care plan for Resident 61's bed against the wall.

During an interview on 1/28/2025 at 3:10 p.m. with the Director of Nursing (DON), the DON stated Resident 61's bed against the wall is considered a restraint because it inhibits movement for the resident.

The DON stated if the resident prefers to have their bed up against the wall, the staff should ensure it is safe for the resident.

During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, undated, the P&P indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.

The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which the staff applied it given that residents physical condition and this restricts his/her ability to change position or place, that device is considered a restraint.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of Resident 46's MDS dated [DATE], the MDS indicated Resident 46 had severe cognitive impairment.

During a concurrent interview and record review on 1/29/2024 at 9:47 a.m., with Registered Nurse Supervisor (RNS) 2, reviewed PASSAR for Resident 5,12,17,34 and 46. RNS 2 stated Resident 5's PASARR Level I screening dated 7/11/2023, indicated a positive Level I screening.

The PASARR level 1 screening indicated Resident 5 needed a PASARR level 11(Level II Mental Health Evaluation is required when the Level I screening result is positive screening). RNS2 stated that the PASARR level II was not done because Resident 5 was unable to participate in the evaluation and the case was now closed. RNS 2 stated Resident 5 has a diagnoses of depression, PTSD and psychosis and is on psychotropic (drugs that affect the brain and nervous system altering mood behavior, and cognitive function) medications. RNS2 stated Resident 12 has a diagnosis of psychosis and is prescribed a psychotropic medication but the PASARR Level I screening indicated Resident 12 did not have a mental illness. RNS 2 stated Resident 12 required a PASARR Level II screening but it was not done.

RNS 2 stated Resident 17's PASARR Level I screening, dated 4/12/2016, indicated a negative Level I screening but should have been positive being Resident 17 had a diagnosis of mental illness. RNS 2 stated Resident 34 has a diagnosis of psychosis. RNS 2 stated Resident 34's PASARR Level I screening dated 8/17/2023, indicated PASARR Level I screening that Resident 34 had no mental illness. RNS 2 stated Resident 46's PASARR Level I screening, dated 4/5/2024, indicated a negative Level I. RNS 2 stated , Resident 46 had a diagnosis of mental illness.

During an interview on 1/29/2025 at 9:47 a.m., with RNS 2, RNS 2 stated she was responsible for the completion of PASARR. RNS 2 stated she does not review the PASARR's when the resident is admitted to the facility. RNS 2 stated ensuring the PASARR is documented accurately is important to the residents so they receive the appropriate follow up and services they may need. RNS2 stated inaccuracy of the PASARR may affect the residents quality of care.

During an interview on 1/29/2025 at 11:31 a.m., with the Director of Nursing (DON), the DON stated it was important to accurately document PASARR Level I to ensure the residents are in the appropriate setting and receive the special services they may need due to their diagnosis of mental illness.

The DON stated the RNS is responsible for reviewing the PASARR's and ensuring they were completed accurately.

During a review of the facility's policy and procedure (P&P) titled, PASARR Completion Policy, dated 9/30/2024, the P&P indicated, The Center will make sure that all admissions have the appropriate PASARR completed.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a concurrent interview and record review on 1/28/2025 at 1:33 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated there was no physician order or care plan for Resident 61's bed against the wall. LVN 4 stated for the safety of the resident, there should be a physician order, and a care plan should have be implemented.

During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated 3/28/2024, the P&P indicated, Each resident's comprehensive care plan is designed to: build on the resident's individualized needs, strengths, preferences; reflect the resident's expressed wishes regarding care and treatment goals.

During a review of the facility's P&P titled, Use of Restraints, undated, the P&P indicated, Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/30/2025 at 2:22 p.m., the Director of Nursing Services (DON) stated all residents at the facility are considered high risk for fall and a fall and/or associated injury to a fall is avoidable/ preventable.

During a review of the facility's policy and procedures (P&P) titled Care Plan Comprehensive revised 3/28/2024, the P/P indicated each resident of the facility will have an individualized comprehensive care plan that includes measurable objectives and timetables to meet each resident's needs to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being.

The P/P indicated the following:

• the residents' identified problem areas, risk and contributing factors associated with the identified

problems, treatment goals, timetables and objectives in measurable outcomes shall be incorporated in the residents' care plan.

• the residents' areas of concern triggered during the resident assessment are evaluated using

specific assessment tools and care plan interventions are designed, revised and updated after careful consideration of the relationship between the resident's problem areas and their causes.

• the assessments of the residents are ongoing and care plans are reviewed and revised as

information about the residents and residents' condition change.

Cross Reference F-F689

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/29/2024 at 11:40 a.m.,with Certified Nursing Assistant 5 (CNA 5) CNA 5 stated it was the responsibility of the nursing assistants assigned to the residents to offer assistance to get up from the bed and sit on their chairs (wheelchairs), as part of the residents' ADL care. CNA 5 stated the residents can get sicker and depressed if they are not assisted with their ADLs and encouraged to enjoy the activities of their choice.

During an interview on 1/29/2024 at 12:08 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated it was necessary for the residents to be assisted and/or supervised to get out of bed and perform their other daily tasks to prevent decline on their mobility and function and complications of weakness and contractures (a permanent tightening of muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).

During an interview on 1/29/2025 at 4 p.m., with the Director of Nursing Services (DON), the DON stated assisting the residents to get out of bed and attend their activities of choice is part of ADL care and should be offered and/ or encouraged to promote a quality of life.

During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting revised 3/2018, the P&P indicated the residents of the facility will be provided care, treatment and services to ensure their activities of daily living (ADLs) do not diminish.

During a review of the facility's P&P titled, Quality of life-Accommodation of Needs revised 8/2009, the (P&P) indicated the facility's environment and staff behavior should be directed toward assisting the residents in maintaining and/or achieving independent functioning, dignity and well-being by ensuring the resident's individual needs and preferences shall be accommodated.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/27/2025 at 10:11 a.m., with CNA 7, CNA 7 stated there is no specific place

Resident 34 refuses to have his nails cleaned or trimmed but it is important to get it done because if not it can cause bacteria to develop under his nails and cause an infection especially when he scratch himself.

During an interview on 1/27/2025 at 2:36 p.m., with Activities Assistance (AA), the AA stated Resident 68's fingernails were long, jagged, and dirty and they should be trimmed and cleaned.

The AA stated long, and unclean fingernails can cause an infection for Resident 68 being he is able to feed himself.

During an interview on 1/27/2025 at 1:04 p.m., the Director of Staff Development (DSD) stated the CNAs are supposed to clean and trim the residents' fingernails during ADL care and as needed to ensure they are free from injuries and free from infection.

The DSD stated nail care is part of personal hygiene and should not be missed.

During an interview on 1/27/2025 at 12:29 p.m., with the Director of Nursing Services (DON), the DON stated the residents should be provided with care and services such as ADL's assistance in a timely manner to prevent the residents from feelings of discomfort and to prevent them from incurring complications of infection and skin injuries related to untrimmed and unclean fingernails.

During an interview on 1/28/2025 at 12:28 p.m., with the Director of Nursing (DON), the DON stated if a resident refuses to have their nails clipped it should be documented and care planned so it can be followed up.

The DON stated when a resident's nails are not clean and trimmed, it could potentially lead to an infection, injury from scratching themselves, discomfort, or negatively impact their dignity.

During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), Supporting 3/2018, the P&P indicated the residents of the facility who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and personal/oral hygiene.

During a review of the facility's P&P titled Fingernails/Toenails, Care of, dated 2/2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection.

Nail care includes daily cleaning and regular trimming.

Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/30/2025 at 2:22 p.m., the Director of Nursing Services (DON) stated all residents at the facility are considered high risk for fall.

The DON stated falls and/ injuries due to a fall are avoidable and preventable.

During a review of the facility's P&P titled, Fall Management revised 3/28/2024, the P&P indicated the facility will ensure the residents will have reduced risk for falls, actual occurrence of falls minimized, injuries addressed incurred after a fall and care provided for a fall.

The P&P indicated the residents will be assessed for fall risk as part of the nursing assessment process to determine the residents' risk thereby providing the residents with appropriate interventions, based on their individualized care plan, to reduce the risk and minimize injury.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated

to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/28/2025 at 12:29 p.m., the Director of Nursing Services (DON) stated the licensed nurses are expected to ensure the residents get their medications safely and appropriately by providing the prescribed liquid hydration to prevent aspiration.

During a review of the facility's policy and procedure (P&P) titled, Encouraging and Restricting Fluids revised 10/2010, the P/P indicated the facility shall provide the residents with fluids necessary to maintain optimum health by ensuring the nursing staff follow the specific instructions concerning the residents' fluid intake.

During a review of the facility's policy and procedure (P&P) titled Administering Medications undated, the P/P indicated the residents' medications are administered in a safe manner by the licensed nurses of the facility.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of Resident 61's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including encephalopathy (brain damage or disease that affects how the brain functions, dysphagia (difficulty swallowing), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 12/23/2024, the MDS indicated Resident 61 was severely cognitively (ability to think, understand, learn, and remember) impaired.

The MDS indicated Resident 61 required partial/moderate assistance (helper does less than half the effort) with eating, hygiene, and dressing.

During a review of Resident 61's Order Summary Report (a list of all currently active medical orders), dated 1/29/2025, the Order Summary Report indicated the following medication orders:

• Allopurinol tablet 300 mg (milligrams- a unit of measurement for mass), 1 tablet by mouth one time a

day for gout, order date 1/14/2025, start date 1/15/2025.

• Cholecalciferol (a dietary supplement used to treat low level of Vitamin D) tablet 1000 unit (a unit of

measurement for mass), give 2 tablets by mouth one time a day for supplement, order date 1/14/2025, start date 1/15/2025.

• Ferrous Sulfate tablet 325mg, give one tablet by mouth one time a day for supplement, order date

9/25/24, start date 9/26/2024.

• Fluticasone Propionate (a medication to treat allergies) Nasal Suspension 50mcg (a unit of

measurement for mass), two sprays in each nostril one time a day for allergic rhinitis (inflammation of the inside of the nose).

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0759 5.

give 10ml by mouth every 12 hours for seizure disorder, order date 1/14/2025, start date 1/14/2025.

• Lidocaine (medication used to relieve pain) external cream 5% (percent), apply to bilateral hips

topically (used on the outside of the body) three times a day for arthritis, order date 12/27/2024, start date 12/27/2024.

During an observation of medication administration on 1/29/2025 between 8:31 a.m. and 8:54 a.m., with Registered Nurse (RN) 1, RN 1 prepared, crushed all together, and administered the following list of medications to Resident 61 in applesauce:

• Allopurinol tablet 300 mg (milligrams- a unit of measurement for mass), 1 tablet by mouth one time a

day for gout, order date 1/14/2025, start date 1/15/2025.

• Cholecalciferol (a dietary supplement used to treat low level of Vitamin D) tablet 1000 unit (a unit of

measurement for mass), give 2 tablets by mouth one time a day for supplement, order date 1/14/2025, start date 1/15/2025.

• Ferrous Sulfate tablet 325mg, give one tablet by mouth one time a day for supplement, order date

9/25/24, start date 9/26/2024.

During an interview on 1/29/2025 at 10:15 a.m., with RN 2, RN 2 stated when administering medication that need to be crushed, the medications should be crushed and administered individually to prevent a potential drug interaction.

During an interview on 1/29/2025 at 10:30 a.m., with RN 1, RN 1 stated she did not crush Resident 61's medications individually but should have done so. RN 1 stated there are some medications that should not be crushed and administered together so she should have not crushed them together and if the resident spits out the medication, RN 2 stated she would not know which medication the resident spit out.

During an interview on 1/29/2025 at 11:38 a.m., with the Director of Nursing, the DON stated medications that require are to be crushed, should be crushed individually because of safety concerns, the resident may spit it out, and some medications should not be mixed.

During a review of the facility's policy and procedure (P&P) titled, Crushing Medications, dated 4/2018, the P&P indicated, Crushing each medication separately and administering each with food is considered best practice.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

Based on observation, interview, and record review, the facility failed to remove an expired

This failure had the potential to result in the use of ineffective medication for the residents.

Findings

During a concurrent observation and interview on 1/30/25 at 10:38 a.m. with Registered Nurse Supervisor (RNS 3) in Station 1, medication cart 1 had Famotidine Tablets (Heartburn Relief), 10 mg acid reducer expiration date of 07/24. RNS 3 stated that all license nurses are responsible for ensuring the medications inside the medication carts are not expired. RNS 3 stated medications that are expired could loose its strength and will not work effectively for the residents.

During an interview on 1/30/25 at 10:40 a.m. with Registered Nurse Supervisor (RNS 2) in station 2, RNS 2 stated that all license nurses are responsible for ensuring that medications are not expired in the medication carts. RNS 2 stated medications that are expired could loose its strength and not work adequately for the residents, and the resident's condition will not improve. RNS 2 stated expired medications could be toxic for the residents and they could go into shock (life-threatening condition that occurs when the body is not getting enough blood flow) and cause death.

During an interview on 1/30/25 at 2:22 p.m. with Director of Nursing (DON), DON stated all license staff are responsible for ensuring the medications in the cart are not expired. DON stated expired medications could cause the residents to have an allergic reaction that could result in death.

During a review of the facility's policy and procedure (P&P) titled, Storage of Medications dated 2020, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications[undated], the P&P indicated Medications are administered in a safe and timely manner as prescribed.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an observation on 1/28/2025 at 12:40 p.m. in the kitchen, the Dietary Aide (DA 1) entered the kitchen and did not perform hand hygiene.

Observed DA 1 was wearing mask below the nose. DA 1 proceeded to the food cart to deliver the food trays to the residents in the facility.

During an interview on 1/28/2025 at 12:42 p.m. with DA 1, DA 1 stated that he should wash his hands upon entering the kitchen. DA 1 stated that he should have washed his hands to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another), which could cause the residents and staff to get sick. DA 1 stated that he did not wash his hand when he entered the kitchen and was not wearing his mask correctly. DA 1 stated it is important to keep his mask over his nose to prevent the spread of germs and potential contamination that could cause the residents to become sick.

During an interview on 1/28/25 at 12:45 p.m. with Dietary Aide (DA 2), DA 2 stated hand washing is important to prevent cross contamination, which could cause the residents to become sick with diarrhea and vomiting.

During an interview on 1/28/25 2:36 p.m. with District Manager (DM), DM stated hand washing should be done upon entering the kitchen, and between tasks to prevent cross contamination. DM stated cross contamination could cause food borne illness that would affect the residents in the facility and cause them to get sick.

During a review of Dietary Aide Job Description, [undated], the Job Description indicated Practices safety, infection control, and emergency procedures according to facility/state/federal/HCSG polices.

During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 9/2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.

During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 9/2023, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

During a review of the facility's P&P titled, Food: Preparation, dated 2/2023, the P&P indicated, All staff will practice proper hand washing techniques and glove use.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

physically capable of caring of the residents.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey indicated the following repeat deficiencies in resident's rights, comprehensive resident centered care plans, pharmacy services, Quality assurance and performance improvements and infection control.

During a concurrent interview and record review on 1/31/2025 at 3:25 p.m. with the Administrator (ADM) the Quality Assurance Performance Improvement (QAPI), The ADM stated she could improve on the facility's QAPI program and that she has not been as diligent as she should have been.

The ADM stated the QAPI program is essential for ensuring the concerns of the facility are addressed in a systematic process to achieve positive outcomes.

During a review of the facility's policy and procedure (P&P), titled Quality Assurance and Performance Improvement (QAPI) Program, dated, 2/2020, the P&P indicated, The facility implements and maintains an ongoing, facility wide data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for the resident's.

The objectives of the QAPI program are to, provide a means to measure current and potential indicators for outcomes of care and quality of life.

Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.

Reinforce and build upon effective systems and process related to the delivery of quality care and services.

Establish systems through which to monitor and evaluate corrective actions.The administrator is responsible for assuring that the facilities QAPI program complies with federal, state and local regulatory agency requirements.

The QAPI committee reports directly to the administrator.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During an interview on 1/29/2024 at 10:30 a.m., with RN 1, RN 1 stated she did not sanitize the blood

which could result in the resident potentially getting sick, hospitalized or dying from infection.

During an interview on 1/29/2025 at 11:38 a.m., with the Director of Nursing (DON), the DON stated the staff are supposed to disinfect equipment between residents to prevent the spread of germs and cross contamination.

During a review of the facility's Registered Nurse (RN) Job Description, dated 5/2022, the RN Job Description indicated, Adhere to the facility infection prevention and control practices.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in a safe and timely manner.

Staff follows established facility infection control procedures for the administration of medications.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (depressed mood causing significant impairment in daily life), post-traumatic stress disorder (unwanted memories of a trauma).

During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognition (ability to think, understand, learn, and remember) is intact.

During a review of Resident 5's History & Physical (H&P) dated 4/5/2024 indicated Resident 5 has the capacity to understand and make decisions.

During an observation on 1/28/2025 at 10:00 a.m., the following rooms were observed, rooms one through 11, 14, 16, and rooms 18-26 did not meet the requirement of 80 square feet per resident.

During an interview on 1/30/2025 at 2:53 p.m.with Resident 5, Resident 5 stated the room is very small and the staff have to reach over my stuff to get gloves .

During a review of the Client Accommodations Analysis Form (CAAF), provided by the Administrator (ADM) on 1/27/25, the CAAF indicated rooms one through 11 and rooms 14, 18 and rooms 18-26 were occupied with two residents per room and had a total square foot measurement of 143 sq. ft.

During an interview on 1/29/2025 at 9:00 a.m., with the Administrator (ADM), the ADM stated she did not know she had to reapply for the room wavier every year. ADM stated she has never been told she cannot use the rooms without the approved room waiver.

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Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

During a review of the Facility's Assessment (a comprehensive evaluation of the residents and

indicated that staff members are provided with training upon hire and as needed on the following topics communication, resident's rights, abuse, infection control, dementia, behavioral health to ensure staff have the training needed to effectively perform their duties.

During a review of the facility's policy and procedure (P&P) titled Competency of Nursing staff dated 05/2019 indicated, all nursing staff must meet the specific competency requirements of their respective Licensure and certification requirements defined by State law. In addition, licensed nurses and nursing assistants employed ( or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

Training and competency evaluations include elements of critical thinking and processes necessary to identify and report resident changes of condition.

The type and amount of this training is based on the facility assessment and is specific to the different skill levels and licensure of staff.

During a review of Resident 69's Minimum Data Set ([MDS] a resident assessment tool) dated 1/6/2025, the MDS indicated Resident 69 was able to make decisions that were reasonable.

The MDS indicated Resident 69 required one person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as transferring from chair/bed-to-chair, toilet transfer and ambulation (the ability to walk from place to place independently, with or without assistive devices), and was incontinent (loss of control) of bladder and bowel functions.

During a review of Resident 69's care plan titled At risk for decreased ability to perform ADLs dated 12/18/2024 related to illness, fall, hospitalization , impaired balance and limited mobility, the care plan indicated a goal for Resident 69 ADLs care needs to be anticipated.

The care plan interventions included to provide cueing (the act of giving a clue or prompt to another person) for safety and sequencing (the process of combining things in a particular order) to maximize his level of function, to provide Resident 69 with one to two persons assist during bed mobility and transfers and to monitor Resident 69's decline in function.

During a concurrenet observation and interview with Resident 69, the following were observed:

1. On 1/27/2025 at 2 p.m., Resident 69 was observed lying in 45 degrees head of bed elevation in bed and stated he was tired of watching television, and just wanted to take a nap because the nursing staff did offer to get him out of bed.

2. On 1/27/2025 at 4 p.m., Resident 69 stated he asked the nursing staff to help him get out of bed to sit on his wheelchair but the nursing staff did not help him.

3. On 1/28/2025 at 9:30 a.m., Resident 69 stated he wanted to get up today but the nursing staff told him to stay in bed. Resident 69 stated he wanted to sit up on his wheelchair to go outside and talk to other people.

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Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055559 B.

Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503