Bay Crest Care Center

F 0635 Level of Harm - Minimal harm or potential for actual harm

instruments. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Notify the supervisor and the Attending Physician of immediate needs that the resident may have.

Residents Affected - Few

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

11/09/2025

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 0641 Level of Harm - Minimal harm or potential for actual harm

information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments. Cross Reference F-F689

Residents Affected - Few

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

11/09/2025

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 - Immediate jeopardy to resident health or safety Residents Affected - Few

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

ADM, the ADM stated that she believed Resident 1 eloped through the front door. The ADM stated the front door was not equipped with an alarm system, and the facility relies on staff at Station 1 to monitor the door.

The ADM stated Resident 1's elopement was avoidable, if staff had been more vigilant in monitoring the front door, and if the elopement risk assessment had been completed accurately, appropriate interventions could have been implemented to better monitor Resident 1. The ADM stated, I'm sure the outcome would have been different. During a review of the Facility's Policy and Procedure (P&P) titled Wandering and Elopement (undated), the P&P indicated The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the residents. if resident is identified as risk for elopement the resident care plan will have strategies and interventions to maintain the resident's safety.

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

11/09/2025

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

is needed from the pharmacyf. Name of pharmacy supplier if other than provider pharmacy.

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

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

11/09/2025

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 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to maintain and implement an ongoing Quality Assurance and Performance Improvement (QAPI) program as required. The facility was unable to provide documentation or evidence of any QAPI activities, committee meetings, or performance improvement projects since 7/17/2025.This failure had the potential to negatively impact the quality of resident care by allowing facility-identified issues to go unaddressed or reoccur, thereby compromising resident safety and regulatory compliance.Findings:During a review of the facility's QAPI plan dated 07/17/2025 indicated that

this was the last recorded meeting of the facility's Quality Assurance (QA) committee.During an interview conducted on 11/09/2025 at 10:26 a.m., with the Administrator (ADM), the ADM stated that the QA committee was expected to meet monthly to review prior concerns, discuss current issues, and revise care plans as needed. The ADM stated that the last QA meeting occurred on 07/17/2025. The ADM stated that failure to hold regular QA meetings places residents' safety at risk and is not aligned with the facility's QAPI policy. During a review of the facility's policy & procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) plan dated 2/2020, the P&P indicated This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care pursue methods to improve care quality, and resolve identified problems. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committeesThe objectives of the QAPI Plan are to:1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services.2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services.3. Provide structure and processes to correct identified quality and/or safety deficiencies.4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome.5. Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability.6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and7. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet