Bay Crest Care Center

F 0725

reference: F-F760

Level of Harm - Minimal harm or potential for actual harm 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

11/03/2025

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

(medication for Parkinson's) Tablet Dispersible 25-100 milligrams, one tablet by mouth three times a day.Citalopram Hydrobromide (medication for depression), one tablet 10 milligram by mouth every 12 hours.Depakote (medication for mania [mental state of an extreme highs or depressive lows]) Oral Tablet Delayed Release 250 milligram, one tablet by mouth two times a day.Visine Solution (eye drops for minor eye irritation) Instill two drops in both eyes three times a day.During a review of Resident 3's admission record, the admission Record indicated the facility re-admitted Resident 3 on 10/25/2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side and essential hypertension (high blood pressure).During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 needed supervision with eating, moderate assistance (helper does less than half the effort) with oral hygiene, and maximal assistance with showering and personal hygiene. 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

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

11/03/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Citalopram Hydrobromide (medication for depression) one tablet 10 milligram by mouth every 12 hours.

Depakote Oral Tablet (medication for mania [mental state of an extreme highs or depressive lows]) Delayed Release 250 milligram, one tablet by mouth two times a day. Visine Solution (eye drops for minor eye irritation) Instill two drops in both eyes three times a day.During a review of Resident 3's admission record,

the admission Record indicated the facility re-admitted Resident 3 on 10/25/2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side and essential hypertension (high blood pressure).During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 needed supervision with eating, moderate assistance (helper does less than half the effort) with oral hygiene, and maximal assistance with showering and personal hygiene. 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.

Event ID:

Facility ID:

If continuation sheet