Bay Crest Care Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 3's Medical Records (Care Plans), there was no documentation to indicate a Care Plan had been created for the use of Resident 3's indwelling urinary catheter. During an interview on 8/18/2025 at 1:22 p.m., Licensed Vocational Nurse (LVN) 3 stated a Care Plan should have been created for the use of Resident 1 and Resident 3's indwelling urinary catheters so that care instructions to monitor, document and report to the physician signs of infection and/or complications were in place. During an interview on 8/19/2024 at 3:43 p.m., the Director of Nursing (DON) stated care plan's were resident centered and must be formulated to fit each resident's needs with a goal to provide care and treatment geared for the resident's safety and well-being. During a review of the facility's Policy and Procedure (P/P) titled, Care Plan Comprehensive dated 8/25/2021, the P/P indicated the facility shall ensure a comprehensive care plan for each resident to include measurable objectives and timetables to meet the residents' medical, physical, mental and psychological needs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

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 0678

staff member to activate the emergency response (code) and call 911. The P&P indicated all rescuers, trained or not, should provide chest compression to victims of cardiac arrest.

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

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 0684 Level of Harm - Minimal harm or potential for actual harm

hour schedule. During a review of the facility's P/P titled, Activities of Daily Living (ADLs), Supporting revised 3/2018, the P/P indicated the facility shall provide residents with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. The P/P indicated the residents who are unable to carry out activities of daily living independently will receive care and services necessary to maintain good nutrition, and hygiene to include but not limited to turning and repositioning.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

time she thought her documentation was good enough. During an interview on [DATE REDACTED] at 3:43 p.m., the DON stated nursing documentation should paint a clear and honest picture of events that occurred to reflect what happened and the care provided. The DON stated when nursing documentation is not clear or accurate, especially during an emergency event, it may leave the reader with unanswered questions and/or confusion about what happened. During a review of the facility's P/P titled, Nursing Documentation, dated [DATE REDACTED], the P/P indicated the purpose of the policy was to communicate patient's status and provide complete, comprehensive, and accessible accounting for care and monitoring provided. The P/P indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation, and complexity.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated all nursing staff including CNAs are CPR certified. The DSD stated all staff were expected to perform chest compressions immediately to save the residents' lives and/or ensure the least complication until paramedics arrived. During an interview on [DATE REDACTED] at 5 p.m., the Administrator stated the facility was not able to include CPR competence in their previous QAPI plan. During a review of the facility's Policy and Procedure (P/P) titled, Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership revised 3/2020, the P/P indicated the facility's QAPI Committee ensures the following: Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services. Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process. Utilize root cause analysis to help identify where identified problems point to underlying systematic problems. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care.

Event ID:

Facility ID:

If continuation sheet