Bay Crest Care Center
BAY CREST CARE CENTER in TORRANCE, CA — inspection on November 3, 2025.
Found 3 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.
Inspection Findings
reference: F-F760
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Crest Care Center
3750 Garnet Street Torrance, CA 90503
SUMMARY STATEMENT OF DEFICIENCIES
During a review of Resident 3's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be administered during the 3 p.m. to 11 p.m. shift:Apixaban (medication for Deep vein thrombosis [condition where a blood clot forms in a deep vein, usually in the lower leg]) Oral Tablet 5 milligrams prophylaxis (prevention), one tablet by mouth two times a day.Gabapentin (medication for nerve pain) Oral Capsule 300 milligrams, one capsule by mouth two times a day.Hydralazine (medication for high blood pressure) 50 milligrams, one tablet by mouth two times a day.During a concurrent phone interview on 11/5/2025 at 10:30 a.m., with the Director of Nursing (DON), Resident 1, 2 and 3's Medication Administration Records (MAR) for 11/2025 were reviewed.
The DON stated for Residents 2 and 3, according to the MAR for 11/1/2025, the medications scheduled for administration during the 3:00 p.m. to 11:00 p.m. shift were not administered.
The DON stated LVN 4 confirmed she did not give the medications on 11/1/2025 for 3:00 p.m. to 11:00 p.m. shift to Residents 2 and 3.
During the continued phone interview and record review on 11/5/2025 at 10:33 a.m., with the DON, Resident 1's MAR for 11/2025 was reviewed.
The DON stated that on 11/3/2025 at 6:30 a.m.
LVN 4 did not administer Resident 1's medications.
The DON stated the nurses assessed Residents 1, 2 and 3 after the discovery of medication errors and reported the incident to the physician and responsible parties.
During a review of the facility's P/P titled Medication Administration Schedule, revised 11/2020, the P/P indicated the medications were administered according to established schedules.
The P/P indicated the exact time of medication administration was documented in the MAR.
Cross-reference: F-F725
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Crest Care Center
3750 Garnet Street Torrance, CA 90503
SUMMARY STATEMENT OF DEFICIENCIES
During a review of Resident 3's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be administered during the 3 p.m. to 11 p.m. shift:Apixaban (medication for Deep vein thrombosis [condition where a blood clot forms in a deep vein, usually in the lower leg]) Oral Tablet 5 milligrams prophylaxis (prevention), one tablet by mouth two times a day.
Gabapentin (medication for nerve pain) Oral Capsule 300 milligrams one capsule by mouth two times a day.
Hydralazine (medication for high blood pressure) 50 milligrams, one tablet by mouth two times a day forDuring a phone interview on 11/3/2025 at 2:35 p.m., with LVN 3, LVN 3 said that on 11/2/2025 from 3:00 p.m. to 11:00 p.m., she administered the scheduled medications and took care of Resident 1, Resident 2, and Resident 3. LVN 3 stated she was unable to sign the MAR when she administered the medications. LVN 3 stated she was going to document as soon as she could.
During a concurrent interview and record review on 11/3/2025 at 3:13 p.m., with Registered Nurse (RN)1, Resident 1's, Resident 2's and Resident 3's Medication Administration Records (MAR) for 11/2025 were reviewed.
RN 1 confirmed and stated none of the medications or tasks for the 3:00 p.m. to 11:00 p.m. shift were documented as completed by the LVN 3. RN 1 stated that after medications or tasks were administered to Resident 1, Resident 2, and Resident 3, the administering licensed nurse should document that it was given right away.
During an interview on 11/3/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON stated documentation needs to be complete and accurate and the nurse should have documented a medication was administered as soon as it was administered to prevent medication errors.
During a review of the facility's policy and procedure (P/P) titled, Charting and Documentation, revised 7/2017, the P/P indicated all services provided to the resident shall be documented in the resident's medical record.
Documentation will be objective, complete, and accurate.
During a review of the facility's P/P titled Medication Administration Schedule, revised 11/2020, the P/P indicated the exact time of medication administration was documented in the MAR.
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.