Bay Crest Care Center

During an interview on 10/14/2025, at 4 p.m., the Director of Nursing (DON) he overheard about the incident between Resident 1 and Resident 2 on 10/8/2025 during a staff huddle.

The DON stated LVN 1 should have reported the allegation of abuse to the ADM on 10/7/2025 when she was made aware by Resident 1 that Resident 2 hit her with a water bottle.

The DON stated all allegations, and suspected abuse should be reported to the ADM, the police, Ombudsman and CDPH immediately and within two hours.

The DON stated failure to report abuse placed Resident 1 at risk for continued abuse, caused a delay and or lack of needed services to Resident 1 and Resident 2, led to a delay in CDPH's investigation, and was a violation of the Federal regulations.

During an interview on 10/14/2025 at 4:15 p.m., the ADM stated she was in the building on 10/7/2025 until almost 11 p.m. but was not informed of the incident Resident 1 and Resident 2 until it was reported to her by the DON on 10/8/2025.

The ADM stated once it was brought to her attention she reported the allegation of abuse to CDPH, law enforcement and the Ombudsman.

The ADM stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours of being made aware of it.

During a review of the facility's Policy and Procedure (P/P) titled, Abuse Prohibition Policy and Procedure dated 2/23/2021, the P/P indicated upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the designee will perform the following, report allegations involving abuse (physical, verbal, sexual mental) not later than two hours after the allegation is made, notify local law enforcement , ombudsman, licensing district office, licensing boards, registries and other agencies as required.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

During telephone interview on 10/14/2025, at 8:30 a.m., Resident 1's Responsible Party (RP) 1 stated on 10/7/2025 at approximately 9:30 p.m., she received a call from Resident 1 reporting that Resident 2 was in her personal living area, yelling at her and hitting her with an object. RP 1 stated she could hear yelling and screaming on the phone. RP 1 stated she was concerned about Resident 1's safety and called the police to perform a wellness check on Resident 1.

During interview on 10/14/2025, at 3:30 p.m., LVN 1 stated when she entered Resident 1 and Resident 2's shared room, Resident 1 appeared very agitated and stated that Resident 2 tried to hit her with a water bottle and she (Resident 1) wanted Resident 2 out of her room and did not want Resident 2 to be her roommate.

During an interview on 10/14/2025, at 8:45 a.m., CNA 1 stated Resident 2 was confused and could be difficult to redirect. CNA 1 stated approximately one month ago, Resident 4 called her to the room that she (Resident 4), Resident 5 and Resident 2 shared to report that Resident 2 would not leave Resident 5's personal living area. CNA 1 stated Resident 2 was sitting in the corner between the wall and Resident 5's bed, staring at Resident 5 and would not leave. CNA 1 stated she required assistance from another staff member (unknown) to redirect Resident 2 back to her side of the room and her bed because Resident 2 began shouting and was difficult to redirect.

During an interview on 10/14/2025, at 3:45 p.m., the ADM stated she was aware of Resident 4's concerns about Resident 2's behavior of invading her (Resident 4) personal space.

The ADM stated she did not inform the nursing staff of Resident 2's behaviors prior to moving Resident 2 out of the room she shared with Resident 4 and Resident 5 on 9/17/2025 due to Resident 2 moving Resident 4's personal items.

The Administrator stated she should have informed the IDT of Resident 2's behaviors of invading her roommate's spaces in 9/2025 so Resident 2's behavior could be discussed and her care plan revised to ensure Resident 2 was provided appropriate supervision.

During an interview on 10/14/2025, at 4 p.m., the Director of Nursing (DON) stated prior to the incident on 10/7/2025 involving Resident 1 and Resident 2, he was not aware of Resident 2's behaviors of wandering into her roommates spaces.

The DON stated based on the most recent MDS assessment dated [DATE] and Resident 2's past multiple behaviors of wandering into her roommate's living areas, the IDT should have met to develop a Care Plan with interventions to keep Resident 2 and other residents safe.

The DON stated the lack of care planning, placed Resident 2' and her roommates were placed at risk for harm.

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 Interdisciplinary Team ([IDT] a team of health care workers from different specialties working together to meet the residents' care needs/goals) in coordination with the resident and or her family/representative, must develop and implement a comprehensive and person centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, mental and psychological need that are identified in the comprehensive assessment.

The P/P indicated the assessments of the residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change.

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