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Complaint Investigation

Bay Crest Care Center

August 19, 2025 · Torrance, CA · 3750 Garnet Street
Citations 5
CMS Rating 1/5
Beds 80
Provider ID 055559
Healthcare Facility
Bay Crest Care Center
Torrance, CA  ·  View full profile →
Inspection Summary

BAY CREST CARE CENTER in TORRANCE, CA — inspection on August 19, 2025.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

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.

jeopardy to resident health or safety

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on [DATE] 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], 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

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During an interview on [DATE] 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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TORRANCE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAY CREST CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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