Bay Crest Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

hyperlipidemia (high cholesterol), congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and history of cardiac arrest (heart attack). The Care Plan indicated the goal included for Resident 3 to avoid complications related to elevated BP or low BP daily for the next three months. The Care Plan interventions included administering medications as ordered, assessing effectiveness and side effects of medications, and reporting abnormalities to the physician.During a review of Resident 3's untitled Care Plan dated 5/1/2022, Resident 3 was at high risk for signs and symptoms of hypoglycemia (low blood sugar (BS) level) and hyperglycemia (high blood sugar level). The Care Plan's goal indicated Resident 3 will be free of all signs and symptoms of hypo/hyperglycemia such as sweating, trembling, thirst, fatigue and weakness for 90 days or until the

review date of 10/26/2025. The Care Plan interventions included which included to administer Metformin HCL oral tablet 1000 mg.During a review of Resident 3's untitled Care Plan dated 5/1/2022, Resident 3 was at risk for injury or complications related to the use of anticoagulant (medication that prevents the blood from forming clots) therapy medication Clopidogrel for CVA prophylaxis. The Care Plan goal indicated Resident 3 will not exhibit signs or symptoms of bleeding for the next 90 days or until the review date of 10/26/2025. The Care Plan interventions included administering anticoagulant as ordered.During a concurrent observation and interview with LVN 1 on 9/2/2025 at 12:08 p.m., LVN 1 was observed administered ten medications (Ascorbic acid tablet 500 milligrams, Aspirin 81 mg oral tablet chewable, Clopidogrel Bisulfate tablet 75 mg, Fish oil oral capsule 1000 mg, Hydrochlorothiazide capsule 12.5 mg, Metformin hydrochloric acid (HCL) oral tablet 1000 mg, Metoprolol succinate extended-release tablet 25 mg, Multi Vitamin tablet, Pioglitazone HCL 30 mg, and Vitamin B12 oral tablet 1000 micrograms) to Resident 3. LVN 1 stated the medications were due to be administered at 9 a.m. but were late because he was busy dealing with the family members of another resident (Resident 4), and the gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) of another resident (resident unknown). LVN 1 stated medications should be administered as ordered because medication is time sensitive, and it could affect other medication administration times either being too close or too far apart. LVN 1 stated he did not call the physician regarding the delay in medication administration. LVN 1 stated he should have called the physician because the resident might require further treatment or monitoring.During an interview on 9/3/2025 at 2:43 p.m., the Director of Nursing (DON) stated if medication is late, the licensed nurse should complete a change in condition (COC), create a care plan, monitor the resident, notify the physician and

the resident's family. The DON stated if LVN 1 was delayed with his medication administration, he should have notified him (DON) and the registered nurse supervisor (RNS). The DON stated when medication is given late, depending on the medication, the resident could have a reaction resulting in a change of condition and would require further monitoring.During a review of the facility's policy and procedure (P/P) titled Change in Condition: Notification of, dated 8/25/2021, the P/P indicated the facility must immediately consult with the resident's physician and/or NP when there is a need to alter treatment significantly (that is,

a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

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

09/03/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

blood sugar (BS) level) and hyperglycemia (high blood sugar level). The Care Plan's goal indicated Resident 3 will be free of all signs and symptoms of hypo/hyperglycemia such as sweating, trembling, thirst, fatigue and weakness for 90 days or until the review date of 10/26/2025. The Care Plan interventions included which included to administer Metformin HCL oral tablet 1000 mg.During a review of Resident 3's untitled Care Plan dated 5/1/2022, Resident 3 was at risk for injury or complications related to the use of anticoagulant (medication that prevents the blood from forming clots) therapy medication Clopidogrel for CVA prophylaxis. The Care Plan goal indicated Resident 3 will not exhibit signs or symptoms of bleeding for

the next 90 days or until the review date of 10/26/2025. The Care Plan interventions included administering anticoagulant as ordered.During a concurrent observation and interview with LVN 1 on 9/2/2025 at 12:08 p.m., LVN 1 administered ten medications (Ascorbic acid tablet 500 milligrams, Aspirin 81 mg oral tablet chewable, Clopidogrel Bisulfate tablet 75 mg, Fish oil oral capsule 1000 mg, Hydrochlorothiazide capsule 12.5 mg, Metformin hydrochloric acid (HCL) oral tablet 1000 mg, Metoprolol succinate extended-release tablet 25 mg, Multi Vitamin tablet, Pioglitazone HCL 30 mg, and Vitamin B12 oral tablet 1000 micrograms) timed for 9 a.m. to Resident 3. LVN 1 stated the medications were late because he was busy dealing with

the family members of Resident 4 and the gastrostomy (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) of another resident. LVN 1 stated medication should be administered as ordered because medication is time sensitive, and it could affect other medication administration times either being too close or too far apart.During an interview on 9/3/2025 at 2:43 p.m., the Director of Nursing (DON) stated medication can be administered one hour before and after the ordered administration time. The DON stated if medication is late, the licensed nurse should complete a change in condition (COC), create a care plan, monitor the resident, and notify the physician and family. The DON stated if LVN 1 was delayed with his medication administration, he should have notified him (DON) and the registered nurse supervisor (RNS). The DON stated when medication is given late, depending on the medication, the resident could have a reaction resulting in a change of condition and would require further monitoring.During a review of the facility's Job Description titled Licensed Vocational Nurse, dated 5/2022, the job description indicated one of the duties of the LVN included administering medication within the scope of practice and according to practitioner orders, report adverse consequences, side effects or any medication errors.During a review of the facility's policy and procedure (P/P) titled Administering Medication dated 4/2019, the P/P indicated medications are administered within one hour of their prescribed time, unless otherwise prescribed.

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

09/03/2025

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 0813

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to monitor and maintain the temperature of the resident refrigerator which contained personal food items, per the facility's policy and procedure (P&P) titled, Refrigerators and Freezers.This deficient practice had the potential to cause bacterial (germs) growth and food borne illnesses (food poisoning - symptoms which include nausea, vomiting, diarrhea, fever, and other flu-like symptoms) for residents consuming refrigerated personal food items.Findings:During a review of the facility's Resident Refrigerator Temperature Log dated 8/2025, the Resident Refrigerator Temperature Log indicated the temperature was not checked (log was blank) on the following days: 8/2/2025 through 8/6/2025, 8/10/2025 through 8/12/2025, 8/15/2025 through 8/18/2025, 8/20/2025, 8/21/2025, and 8/23/2025 through 8/27/2025.During an observation on 8/27/2025 at 11:50 a.m.,

the resident refrigerator was observed with the thermometer inside the refrigerator reading 60 degrees Fahrenheit (scale for measuring temperature). In the resident refrigerator there was a carton of extra-large brown grade A eggs without resident name/identification of who the eggs belonged. The resident refrigerator was noted to have other food items such as cake, and other bagged/sealed food items.During

an interview on 8/27/2025 at 11:55 a.m., Licensed Vocational Nurse (LVN) 5 stated she was responsible for checking the refrigerator since she was the charge nurse for station 1, but forgot to check it during the beginning of her shift. LVN 5 stated she was unsure if 60 degrees Fahrenheit was an appropriate refrigerator temperature or not. LVN 5 stated if food items are not stored at the proper temperature, it may not be safe for residents to eat.During an interview on 8/27/2025, at 3:15 p.m., the Director of Nursing (DON) stated he had just checked the resident food refrigerator temperature, which was still at 60 degrees Fahrenheit, and that the facility threw away all the food items to prevent residents from eating potentially contaminated food.During a review of the facility's policy and procedure (P/P) titled, Refrigerators and Freezers, dated 11/2022, the P/P indicated refrigerators are to be maintained in good working condition and foods are to be kept at or below 41 degrees Fahrenheit. The P/P indicated refrigerator and freezer temperatures should be checked daily when first opening and closing in the evening.

Residents Affected - Some

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

09/03/2025

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 0908

Keep all essential equipment working safely.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure one of three facility doorbells were functioning. This failure resulted in Resident 1 having to wait several minutes for a staff member to hear Resident 1 knocking on the door after returning to the facility from an appointment.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension ([HTN] high blood pressure) and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting

in leg swelling).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/6/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact.During an interview on 9/3/2025 at 8:32 a.m., with Resident 1, Resident 1 stated

after being dropped back off to the facility after her appointment (unknown date and time), she was attempting to ring the doorbell outside hallway 2's entrance and found that the doorbell was not working.

Resident 1 stated she had to knock several times before one of the staff members finally heard her knocking and her in. Resident 1 stated she was frustrated that the doorbell was not working and had to wait several minutes outside the facility before a staff member realized she was there. Resident 1 stated that had the doorbell worked, she wouldn't have had to wait outside for so long. During a concurrent observation and interview on 9/3/2025 at 9:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN unlocked hallway 2's door, pushed the doorbell, and validated that it did not work. LVN 1 stated the doorbell should work so the staff are aware when a resident is waiting to come back from an appointment. LVN 1 stated it's important that the doorbell works because it is hot outside and the residents may be waiting for a long period of time because no one hears them knocking. LVN 1 stated having to wait outside could cause the residents to feel upset.During an interview on 9/3/2025 at 12:12 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated it is unfair to the residents to make them wait outside which could cause them to become impatient and upset.During an interview on 9/3/2025 at 1:51 p.m., with the Maintenance Director (MD), MD stated he was unaware there was a doorbell at the hallway 2 door. MD stated the doorbell should work so the residents do not have to wait a long time to get into the facility, especially if it's hot outside, which could cause the residents to feel frustrated.During a concurrent observation and interview on 9/3/2025 at 2:42 p.m., with the Director of Nursing (DON), the DON validated the doorbell at the hallway 2 door is not working but should be. The DON stated the purpose of the doorbell is for the residents to be able to notify staff that they are waiting outside so staff can unlock the door and let them into the facility after getting dropped off. The DON stated this is their home and the doorbell should work so they could get back into their home and not being able to do so could cause them to feel bad, angry, and uncomfortable.During a

review of the facility's policy and procedure, (P&P) titled, Maintenance Services, dated 12/2009, the P&P indicated, the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel include maintaining the building in good repair and free from hazards.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet