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Complaint Investigation

Bay Crest Care Center

February 23, 2026 · Torrance, CA · 3750 Garnet Street
Citations 2
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 February 23, 2026.

Found 2 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

FF0656
Resident Assessment and Care Planning Deficiencies

During a review of Resident 1's Nurses Progress Notes dated 11/15/2025, the Nurses Progress Notes indicated Resident 1 refusing to be showered.

During a review of Resident 1's Interdisciplinary (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Care Conference Note dated 11/24/2025, the IDT Care Conference Note indicated Resident 1 refusing meals and medications.

During a review of Resident 1's Follow-Up Note dated 12/26/2025, the Follow-Up Note indicated Resident 1 refused vital signs.During a concurrent interview and record review on 2/20/2026 at 2:44 p.m. with Licensed Vocational Nurse (LVN) 1, reviewed Resident 1's care plans. LVN 1 stated that there was no care plan developed for Resident 1's refusal of care. LVN 1 stated a care plan should have been developed so staff would be aware of the resident's needs and know how to appropriately respond. LVN 1 stated having a care plan addressing refusal of care was important because the lack of one could place Resident 1 at risk for skin breakdown and the care plan serves as a communication tool for staff.

During an interview on 2/20/2026 at 3:59 p.m., with the Director of Nursing (DON), the DON stated when a resident refuses care, a care plan should be developed to help guide the staff on how to direct care for the residents.

During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, dated, 8/25/2021, the P&P indicated, Each resident's comprehensive care plan is designed to incorporate identified problem areas and incorporate risk and contributing factors associated with identified problems.

Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

055559 02/23/2026

Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

stated that revising a care plan after a fall was important because it identifies updated interventions

indicated, A individualized comprehensive care plan that includes measurable objectives and

developed for each resident.

The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment.

Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.

When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident.

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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