Health inspection·November 3, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient licensed nurses were available to pass medications to three out of three sampled residents sampled (Resident 1, 2 and 3). On 11/1/2025, from 3:00 p.m. to 11:00 p.m., Resident 2 did not receive four medications and Resident 3 did not receive three medications. On 11/2/2025, from 11:00 p.m. to 11/3/2025 at 7:00 a.m., Resident 1 did not receive two medications.The deficient practices resulted in scheduled medications not being administered to residents, and had the potential to result in medical complications from not receiving their scheduled medications. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility readmitted Resident 1 on 7/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness, affecting the arm, leg, and sometimes the face) following cerebral infarction (loss of blood flow to the brain) affecting the left dominant side, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high levels of fats in the blood).During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 10/24/2025, the MDS indicated Resident 1 had intact cognition (ability to make decisions of daily living). The MDS indicated Resident 1 needed assistance with eating, maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 1's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be administered during the 11 p.m. to 7 a.m. shift:Januvia (medication for DM) Oral Tablet 50 milligrams (mg - a unit of measure), one tablet by mouth one time a day before breakfastReglan (medication to treat stomach issues) Oral Tablet 5 mg , one tablet by mouth three times a day.During a review of Resident 2's admission record, the admission Record indicated the facility admitted Resident 2 on 4/6/2024 with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (medical condition characterized by involuntary, uncontrolled movements, which can include writhing, twisting, or jerking) and fluctuations (periods of alternating improvement and worsening of motor symptoms), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental illness characterized by pervasive worry and apprehension).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. Resident 2 needed maximal assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 2's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be Page 1 of 7 055559 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered during the 3 p.m. to 11 p.m. shift:Carbidopa-Levodopa Tablet Dispersible (medication for Parkinson's) 25-100 mg one tablet by mouth three times a day.Citalopram Hydrobromide (medication for depression) one tablet 10 mg by mouth every 12 hours.Depakote Oral Tablet Delayed Release (medication for mania [mental state of an extreme highs or depressive lows])250 mg, 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], the MDS indicated Resident 3's cognition was severely impaired. 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 Oral Tablet 5 mg (medication for Deep vein thrombosis [condition where a blood clot forms in a deep vein, usually in the lower leg]) prophylaxis (prevention), one tablet by mouth two times a day.Gabapentin Oral Capsule (medication for nerve pain) 300 mg, one capsule by mouth two times a day.Hydralazine (medication for high blood pressure) 50 mg, one tablet by mouth two times a day.During a review of the facility's untitled document of inhouse census (number of residents in the facility) for 11/1/2025 and Nursing Staffing Assignment and Sign-in sheet, for 11/1/2025 3:00 p.m. to 11:00 p.m., the sheet indicated Licensed Vocational Nurse (LVN) 4 and 5 were responsible for administering medications as scheduled to all the residents. The census indicated there were 68 residents.During a review of the facility's untitled document of inhouse census for 11/2/2025 and Nursing Staffing Assignment and Sign-in sheet, for 11/2/2025 11:00 p.m. to 7:00 a.m., the sheet indicated LVN) 4 (whose shift started on 11/1/2025 at 3:00 p.m.), worked until 4:00 a.m. and left the facility. The Nursing Staffing Assignment and Sign-in sheet indicated there was no replacement for LVN 4 until 11/2/2025 at 7:00 a.m. The sheet indicated there was only one LVN for 68 patients from 4:00 a.m. to 7:00 a.m. The census indicated LVN 4 covered 35 residents and when she left LVN 6 had all 68 residents. During a concurrent phone interview and record review on 11/5/2025 at 10:30 a.m., with the Director of Nursing (DON), the facility's Nursing Staffing Assignment and Sign-in sheet, for 11/1/2025's 3:00 p.m. to 11:00 p.m. shift., was reviewed and the DON confirmed there were 2 LVN's and one new LVN in orientation. Only two LVNs were responsible for 69 residents for the 3:00 p.m. to 11:00 p.m. shift. The DON stated LVN 4 confirmed she did not give the medications on 11/1/2025 during the 3:00 p.m. to 11:00 p.m. shift to Resident 2 and 3. During the continued phone interview and record review on 11/5/2025 at 10:33 a.m., with the DON, the facility's Nursing Staffing Assignment and Sign-in sheet, for 11/2/2025 at 11:00 p.m. to 7:00 a.m. shift, was reviewed and the DON confirmed that LVN 4 left at 4:00 a.m. and the oncoming shift LVN at 7:00 a.m. The DON stated that not having another licensed and seasoned nurse was unacceptable. The DON stated that on 11/3/2025 at 6:30 a.m. the medication for Resident 1 was not administered. The DON stated there should be another licensed nurse. The DON stated the facility does not use the services of a staffing agency to assist with staffing needs. During a review of the facility's policy and procedure (P&P) titled, Staffing revised 10/2017, the P&P indicated the facility provides enough staff with the skills and competency necessary to provide care and services for all residents in accordance with residents' plan of care and the facility assessment. During a review of the facility's Facility Assessment, revised 6/11/2025, the facility assessment indicated the facility will have sufficient staff to meet the needs of the residents at any given time. Cross 055559 Page 2 of 7 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0725 reference: F760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055559 Page 3 of 7 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three out of three sampled residents (Resident 1,2, and 3) received scheduled medications as ordered.a) On 11/1/2025, during the 3:00 p.m. to 11:00 p.m. shift, Resident 2 did not receive his medications including Carbidopa-Levodopa (medication for Parkinson's [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Citalopram (medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest], Depakote , (medication for mania [mental state of an extreme highs or depressive lows]) Visine eye drops (eye drops for minor eye irritation). Resident 3 did not receive his medications including Apixaban (medication for Deep vein thrombosis [condition where a blood clot forms in a deep vein, usually in the lower leg]) prophylaxis (prevention), Gabapentin (medication for nerve pain), and hydralazine (medication for high blood pressure). b) On 11/2/2025, during the 11:00 p.m. to 7:00 a.m. shift, Resident 1 did not receive her 6:30 a.m. medications including Januvia (medication for diabetes disorder characterized by difficulty in blood sugar control]) and Reglan (medication to treat stomach issues). These deficient practices had the potential to result in a range of consequences depending on the type of drug and the condition being treated, from reduced effectiveness of the treatment to worsening of symptoms or potentially serious health complications. Findings: During a review of Resident 1's admission record, the admission Record indicated the facility readmitted Resident 1 on 7/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness, affecting the arm, leg, and sometimes the face) following cerebral infarction (loss of blood flow to the brain)affecting the left dominant side, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high levels of fats in the blood).During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 10/24/2025, the MDS indicated Resident 1 had intact cognition (ability to make decisions of daily living). Resident 1 needed assistance with eating, maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 1's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be administered during the 11 p.m. to 7 a.m. shift:Januvia (medication for DM) Oral Tablet 50 milligrams, one tablet by mouth one time a day before breakfast.Reglan (medication to treat stomach issues) Oral Tablet 5 milligrams , one tablet by mouth three times a day.During a review of Resident 2's admission record, the admission Record indicated the facility admitted Resident 2 on 4/6/2024 with a diagnosis including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (medical condition characterized by involuntary, uncontrolled movements, which can include writhing, twisting, or jerking), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental illness characterized by pervasive worry and apprehension).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 needed maximal assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 2'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:Carbidopa-Levodopa Residents Affected - Some 055559 Page 4 of 7 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (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], 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: F725 055559 Page 5 of 7 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure three of three residents' (Resident 1 to 3) Medication Administration Record (MAR) for 11/2/2025 were correctly documented. The deficient practice resulted in an inaccurate depiction of services and care rendered and had the potential to result in medication errors.Findings: During a review of Resident 1's admission record, the admission Record indicated the facility readmitted Resident 1 on 7/19/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness, affecting the arm, leg, and sometimes the face) following cerebral infarction (loss of blood flow to the brain)affecting the left dominant side, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hyperlipidemia (high levels of fats in the blood).During a review of Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 10/24/2025, the MDS indicated Resident 1 had intact cognition (ability to make decisions of daily living). Resident 1 needed assistance with eating, maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 1's Order Summary, as of 11/3/2025, the Order Summary indicated the following medication orders to be administered from 3 p.m. to 11 p.m. shift: Advair Diskus Inhalation Aerosol Powder Breath Activated (medication for COPD) 250-50 microgram (a unit of measure) per actuation (dose of inhaler), one puff inhale orally two times a day. Cilostazol (medication for symptoms of intermittent claudication [condition caused by poor blood flow to the legs]) Tablet 100 milligrams (a unit of measure), one tablet by mouth two times a day.Ferrous Sulfate (nutritional supplement) Tablet 325 milligrams, one tablet by mouth two times a day. Fluticasone Propionate Nasal Suspension (medication for allergies) fifty microgram per actuation, one spray in both nostrils two times a day. Glipizide (medication for DM) Oral Tablet , five milligrams, one tablet by mouth two times a day.Losartan Potassium (medication for high blood pressure) Oral Tablet 50 milligrams, one tablet by mouth two times a day.Melatonin Oral Tablet (sleep supplement) three milligrams one tablet by mouth at bedtime. Metoprolol Tartrate (medication for high blood pressure) Oral Tablet fifty milligrams, one tablet by mouth two times a day. Restoril Oral Capsule (medication to help induce sleep), 30 milligrams by mouth at bedtime. Simvastatin Oral Tablet (medication for hyperlipidemia) 40 mg by mouth at bedtime.During a review of Resident 2's admission record, the admission Record indicated the facility admitted Resident 2 on 4/6/2024 with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (medical condition characterized by involuntary, uncontrolled movements, which can include writhing, twisting, or jerking), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and anxiety disorder (mental illness characterized by pervasive worry and apprehension).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 needed maximal assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, showering, and personal hygiene.During a review of Resident 2'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: Carbidopa-Levodopa Tablet Dispersible (medication for Parkinson's) 25-100 milligrams one tablet by mouth three times a day. 055559 Page 6 of 7 055559 11/03/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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], 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. 055559 Page 7 of 7