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Complaint Investigation

Bay Crest Care Center

November 9, 2025 · Torrance, CA · 3750 Garnet Street
Citations 5
CMS Rating 1/5
Beds 80
Provider ID 055559
Healthcare Facility
Bay Crest Care Center
Torrance, CA  ·  View full profile →
Inspection Summary

BAY CREST CARE CENTER in TORRANCE, CA — inspection on November 9, 2025.

Found 5 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.

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Inspection Findings

FF0635
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

During a review of 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

is needed from the pharmacyf.

Name of pharmacy supplier if other than provider pharmacy.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bay Crest Care Center

3750 Garnet Street Torrance, CA 90503

SUMMARY STATEMENT OF DEFICIENCIES

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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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TORRANCE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAY CREST CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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