Bay Crest Care Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **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 sampled residents (Resident 2), who was provided a shower, was not left exposed with his uncovered buttocks visible while being transferred through the facility's hallway to his bedroom. This deficient practice resulted in Resident 2 feeling embarrassed and had the potential for mistrust with care and services provided by the facility staff.

Findings

During a review of Resident 2's admission Record (Face Sheet) the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with a diagnosis of generalized weakness. During a review of Resident 2's History and Physical (H&P) dated 10/5/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 10/3/2025, the MDS indicated Resident 2 required partial/moderate assistance (helper performs less than half of the effort for an activity) with toilet hygiene, and shower/bath . During an observation on 10/17/2025 at 9:15 a.m., Certified Nursing Assistant (CNA) 1 was observed pushing Resident 2 in a shower chair from the shower room through the hallway to

the resident's bedroom. Resident 2 had a bath towel covering the front of his body but Resident 2's uncovered buttocks was visible and hanging through the shower chair. During an interview on 10/17/2025 at 10:15 a.m., Resident 2 stated he felt something cold on his buttocks and knew at that time that his buttocks must have been uncovered and hoped no one saw it because that would be embarrassing. During

an interview on 10/17/2025 at 10:26 a.m., CNA 1 stated he usually wrapped a bath towel around resident's entire body following their shower and he did not know that Resident 2's buttocks was uncovered and visible. CNA 1 stated having the resident's buttocks visible for all to see could be embarrassing to Resident 2 The Director of Nursing (DON) stated Resident 2 should have been fully covered following his shower, so his buttocks was not uncovered and visible During a review of the facility's undated Policy and Procedure (P/P), titled Dignity the P/P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self -worth and selfesteem. Staff promote, maintain and protect the resident's privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/17/2025

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

During an interview on 10/17/2025 at 12:06 p.m., Licensed Vocational Nurse (LVN) 1 stated that on 10/7/2025 at 11:30 a.m., Resident 1 told her he burned his left leg while cooking eggs. LVN 1 stated she told the ADM on 10/7/2025 about Resident 1 getting burned when he used the egg cooker. LVN 1 stated

she knew Resident 1 had an egg cooker in his room, because when she went there daily to treat his other wounds, she would see the egg cooker on the floor. LVN 1 stated residents were not allowed to have heating/cooking devices in their room because it could be dangerous, causing a fire and/or burns to the resident(s) but she did not tell anyone prior to his report of a burn that he had the egg cooker. During an

interview on 10/17/2025 at 12:26 p.m., the DON stated he knew Resident 1 had an egg cooker in his room at one time, but he thought the egg cooker was finally gone. The DON stated he never checked Resident 1's room to verify if the egg cooker was gone. The DON stated if he knew the egg cooker was still in Resident 1's room, he would have checked the egg cooker to make sure it was functioning properly, educated Resident 1 on using the device safely and created a care plan. During an interview on 10/17/2025 at 12:41 p.m., the ADM stated, she believes Resident 1 came to the facility with an egg cooker, when she found out about it, she told him he could not have it in his room (date unknown). The ADM stated she did not check Resident 1's room to verify if the egg cooker was gone because of the resident's behavior of yelling, cursing, calling staff names and accusing staff of stealing his personal items, and because the Resident initially hid the egg cooker in a box that was in his room. The ADM stated because the resident's egg cooker looked old and dirty, she purchased an egg cooker and eggs and kept them in the facility's kitchen for Resident 1's use, whenever he wanted eggs. The ADM stated she was notified by LVN 1 (10/7/2025) that Resident 1 had burned himself. The ADM stated she could not remember if LVN 1 told her

the burn was from an egg cooker. The ADM stated she did not go to Resident 1's room after the burn was reported to her to check on Resident 1. The ADM stated residents were told they were not allowed to have heating devices in their room because of safety issues. The ADM stated she never gave approval for Resident 1 to have a cooking appliance in his room because it was not safe. During a review of the facility's undated P&P titled, Electrical Appliances the P&P indicated only authorized electrical appliances will be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,) within their living area, unless approved, in writing, by the Administrator, or his/her designee. Should electrical appliances be permitted, each must be in good working order, free of frayed cords and UL ([Underwriters Laboratories] a product that has been tested and certified by an independent safety science company, to meet specific safety, performance, or quality standards) approved .

Event ID:

Facility ID:

If continuation sheet