Health inspection·November 9, 2025

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 admission orders were entered and implemented in a timely manner for one of three sampled residents (Resident 1) upon admission on [DATE] at approximately 9:00 p.m. The facility failed to:1. Initiate or carry out Resident 1's physician orders on the day of admission, despite the resident having multiple serious medical conditions. Licensed staff were unaware of Resident 1's presence in the facility for over two hours, and no admission packet or orders were available or processed during that time. This deficient practice placed Resident 1 at significant risk for harm, including potential neglect and unmet medical needs.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted from GACH 1 to the facility on [DATE] with the diagnosis including acute myocardial infraction (MI-heart attack), presence of coronary angioplasty implant and graft (minimally invasive procedure used to open narrowed or blocked coronary [arteries which surround and supply the heart] arteries), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) chronic obstructive pulmonary disease (COPD-lung disease) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During an interview on 11/07/2025 at 8:45 a.m., Resident 2, who shared a room with Resident 1, stated that Resident 1 arrived at their shared room around 9:00 p.m. on 11/03/2025.During an interview on 11/07/2025 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that she was unaware Resident 1 had been admitted to the facility until she observed him in bed during her rounds at approximately 11:30 p.m. on 11/03/2025. LVN 4 stated that she had not received a report on Resident 1 and that there was no admission packet or hospital orders available. LVN 4 stated she did not enter any admission orders into the electronic system. LVN 4 stated that she should have been informed of Resident 1's needs prior to providing care and expressed concern that not knowing the resident's name or medical conditions posed a risk for neglect.During an interview on 11/08/2025 at 8:22 a.m., with Registered Nurse Supervisor 2 (RNS2), RNS 2 stated that a recurring issue with admissions was that they often occur during the 3:00 p.m. to 11:00 p.m. shift, when there was no RNS to oversee the admission process. RNS 2 stated that admission orders should be initiated immediately upon the residents' arrival to ensure appropriate and timely care.During an interview on 11/09/2025 at 12:27 p.m., with the Administrator (ADM), the ADM stated that admission orders were expected to be initiated within 30 minutes of a resident's arrival. The ADM stated the failure to initiate timely orders as a horrible [NAME] effect that compromises resident safety and acknowledged that the facility failed to follow protocol. During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse dated 9/2012, the P&P indicated The purpose of this procedure is to gather 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 Residents Affected - Few Page 1 of 14 055559 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

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 055559 Page 2 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0641 Ensure each resident receives an accurate assessment. 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 one of three sampled residents (Resident 1) was accurately assessed for the risk of elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision).This deficient practice resulted in an inaccurate assessment of Resident 1's risk for elopement and the facility's failure to develop and implement a care plan with appropriate interventions to prevent potential elopement.Findings:During a review of GACH 1's Physical Therapy (PT (licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) assessment dated [DATE], the PT assessment indicated Resident 1 was alert, able to ambulate 10 feet (ft-unit of measure) with a FWW. The PT Assessment indicated Resident 1's gait (walking) was slow, and Resident 1 complained of fatigue (lack of energy). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted from GACH 1 to the facility on [DATE] with the diagnosis including acute myocardial infraction (MI-heart attack), presence of coronary angioplasty implant and graft (minimally invasive procedure used to open narrowed or blocked coronary [arteries which surround and supply the heart] arteries), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) chronic obstructive pulmonary disease (COPD-lung disease) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 1's Joint Mobility Screening (a series of tests to assess a person's joint health and flexibility) dated 11/04/2025 , the Joint Mobility Screening indicated Resident 1 had full range of motion (FROM- performing an exercise without limitations) to bilateral (both) upper extremities (BUE-right and left arm) and bilateral lower extremities (BLE - right and left leg).During a review of Resident1's Elopement Risk Assessment, dated 11/04/2025, the Elopement Risk Assessment indicated Resident 1 could not walk or self-propel wheelchair independently. During a concurrent interview and record review on 11/7/2025 at 12:03 p.m. with the Physical Therapy Director (PTD), Resident1's Joint Mobility Screening dated 11/04/2025 was reviewed. The PTD stated she had completed the assessment and stated Resident 1 demonstrated full range of motion in both upper and lower extremities. PTD stated Resident 1 was able to walk to the bathroom using a FWW with minimal assistance but required frequent safety cues due to being impulsive while walking.During a concurrent interview and record review on 11/7/2025 at 1:59 p.m. with RNS 1, Resident 1's Elopement Risk assessment dated [DATE] and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 1 stated she had completed the Elopement Risk Assessment for Resident 1. RNS 1 stated that prior to completing the assessment, she interviewed Resident 1 and reviewed Resident 1's GACH 1's record. RNS 1 stated she observed Resident 1 was unresponsive, only answering questions selectively. RNS 1 stated she observed Resident 1's arms were moving erratically, and when asked if he could walk, Resident 1 did not provide a clear yes or no response. RNS 1 stated based on her observations, Resident 1 was non-ambulatory (not walking) and unable to self-propel in a wheelchair. RNS 1 stated that in her assessment, he looked like he could not walk. Registered Nurse Supervisor (RNS) 1 stated that Resident 1 was at high risk for elopement. RNS stated Resident 1's elopement risk assessment was inaccurate. During an interview on 11/09/2025 at 12:27 p.m. with the Administrator (ADM), the ADM stated that she was made aware Resident 1's elopement risk assessment had been completed inaccurately. The ADM stated that appropriate interventions should have been implemented to monitor Resident 1 for elopement. The ADM stated that when assessments were inaccurate, residents' safety is placed at risk.During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse dated 9/2012, the P&P indicated, The purpose of this procedure is to gather Residents Affected - Few 055559 Page 3 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

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 F689 Residents Affected - Few 055559 Page 4 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who required minimal assistance with ambulation (walking) using a front wheel walker (FWWassistive walking device), did not exit through the unsupervised, non-alarmed front door without staff knowledge. The facility failed to: 1. Ensure there was a system in place to monitor the facility's front door after 6:30 pm during times when the receptionist was not present to prevent residents from leaving the facility without staff knowledge. 2. Ensure Resident 1 was accurately assessed for the risk of elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) and developed a plan of care with intervention to prevent elopement. Resident 1 was assessed as low risk for elopement due to being unable to ambulate (walk) and unable to self-propel a wheelchair. According to Resident 1's general acute care hospital (GACH) 1 record titled Physical Therapy Notes and an interview with the facility's occupational Therapist (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Resident 1 required minimal assistance ( a person can perform most of the walking task independently but requires some help which may include minor physical guidance, verbal cues, or setup) with ambulation using a FWW. 3. Ensure there were interventions in place to ensure Resident 1's safety and address possible elopement. 4. Ensure staff responded to the alarm when the emergency exit door, located on Station 3, was alarming on 11/7/2025 for eight minutes to ensure door was secure and no resident had eloped (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision). As a result of these deficient practices, Resident 1 eloped from the facility on 11/4/2025 at approximately 8:00 p.m. On 11/4/2025 Resident 1 was found at a local restaurant located approximately one mile away from the facility. While at the restaurant Resident 1 complained of shortness of breath, 911 ( a phone number used to contact the emergency services) was called and the resident was transported to the GACH. Upon arrival at the GACH on the same day at 11:04 p.m., Resident 1 experienced a cardiac arrest (heart attack) and was pronounced dead on 11/4/2025 at 11:39 pm. These deficient practices placed 13 residents, assessed as being at risk of elopement, at an increased risk of leaving the facility's premises and being exposed to adverse environmental conditions (rain and/or cold), hypothermia (a dangerously low body temperature), injuries from motor vehicle accidents, medical complications, and/or death. On 11/08/2025 at 1:35 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent the resident's elopement from the facility on 11/04/2025. On 11/10/2025 the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/10/2025 at 1:26 p.m., in the presence of the facility's Administrator (ADM).The IJRP included the following immediate actions: 1. On 11/5/25, the Elopement Evaluation for 73 active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). There were 13 residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered 055559 Page 5 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1 -involves a sitter or companion to prevent harm) monitoring, sitter (a person who provides non-medical supervision to a resident), hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice. 2. On 11/5/25, the care plan for the 13 residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions of the 13 residents included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Two residents currently placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (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) after 30 days from 11/9/25 for continuation or discontinuation. Three residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT after 30 days from 11/9/25 for continuation/discontinuation. 3. On 11/5/25, the IDT initiated a care plan meeting for the 13 residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse on 11/9/2025. 4. On 11/5/2025, the Maintenance Director checked six facility egress doors (door that provides safe and accessible exit route) and tested all six audible door alarms for functionality. There were no negative findings identified in all six exit doors. On 11/8/25, the Maintenance Director checked facility egress door and tested all seven audible door alarms for functionality. There were no negative findings identified in all seven exit doors. Seven egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS (mechanism to communicate maintenance services needed), Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions. 5. On 11/5/2025, the DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all six exit doors are attended and checked for resident safety. On 11/5/2025, the DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all six exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. On 11/8/25, Staff training provided by the DSD/Designee on monitoring all seven exit doors and ensuring all seven exit doors are secured and alarm in place. Staff training with emphasis on ensuring all seven exit doors are secured and an alarm in place:a. From 7am to 8pm daily, the front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the seven exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the seven exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned 055559 Page 6 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Nursing staff to document the checking of all seven doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift. 6. On 11/5/2025, the DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan. 7. The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle (daily stand-up meeting ) and Point Click Care Communication ( messaging tool that enables healthcare professionals to exchange resident information in real time) Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily (Monday to Friday) Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends (Saturday and Sunday). If pink wristbands are not in place, Department Managers (Monday to Friday) will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1. 8. On 11/5/2025, the Medical Director was informed by DON regarding the incident. No new orders were given. 9. On 11/6/25, the Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station (Stations 1, 2 ,3) and the reception area. 10. On 11/6/2025, the DSD/Designee placed pink wristbands to 13 residents as an elopement identifier. 11. On 11/6/2025, The Maintenance Director initiated daily checks on all 6 exit doors to ensure they were properly latched and alarms functioning. 12. Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of seven exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of seven exit doors as assigned hourly. 13. On 11/8/25, the facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area. 14. On 11/8/25, the receptionist hours were increased from 7 a.m. to 8 p.m., daily, including weekends, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place 15. On 11/8/25, The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated on 11/5/25 regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and 055559 Page 7 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few procedures. 16. The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed. Actions to prevent occurrence or recurrence: 1. On 11/9/2025, the facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed. 2. On 11/6/2025, the facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily. 3. DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation. 4. All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained. Findings: During a review of GACH 1's Physical Therapy (PT (licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) assessment dated [DATE], the PT assessment indicated Resident 1 was alert, able to ambulate 10 feet (ft-unit of measure) with a FWW. The PT Assessment indicated Resident 1's gait (walking) was slow, and Resident 1 complained of fatigue (lack of energy). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted from GACH 1 to the facility on [DATE] with the diagnosis including acute myocardial infraction (MI-heart attack), presence of coronary angioplasty implant and graft (minimally invasive procedure used to open narrowed or blocked coronary [arteries which surround and supply the heart] arteries), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) chronic obstructive pulmonary disease (COPD-lung disease) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's Joint Mobility Screening (a series of tests to assess a person's joint health and flexibility) dated 11/04/2025 , the Joint Mobility Screening indicated Resident 1 had full range of motion (FROM- performing an exercise without limitations) to bilateral (both) upper extremities (BUE-right and left arm) and bilateral lower extremities (BLE - right and left leg). During a review of Resident 1's Occupational Therapy Evaluation (OT-profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), dated 11/04/2025, the OT evaluation indicated Resident 1 had excellent rehab potential as evidenced by the ability to follow multi-step directions, active participation in skilled treatment and a high prior level of function. During a review of Resident1's Transfer Reposition assessment dated [DATE], the Transfer Reposition Assessment indicated Resident 1 was able to bear weight (stand) on both legs and that Resident 1 was able to consistently perform a stand and pivot transfer (move from one place to the other) with limited assistance. During a review of Resident 1's admission assessment dated [DATE], the admission Assessment indicated Resident 1 was alert to person, had clear speech, was able to follow simple commands, and make his needs known, he was able to understand others. The admission Assessment indicated Resident 1 was confused with poor safety judgement. The admission Assessment indicated Resident 1 did not use any assistive devices for ambulation (walking). During a review of Resident1's Elopement Risk Assessment, dated 11/04/2025, the Elopement Risk Assessment indicated Resident 1 could not walk or self-propel wheelchair independently. During a review of Resident 1's Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate 055559 Page 8 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few intervention, may result in complications or death) dated 11/04/2025, the COC indicated Resident 1 was last seen at 7:20 p.m. on 11/04/2025 in his room. The COC also indicated that at 8:30 p.m. was when staff first noticed that Resident 1 had eloped from the facility. During a review of Resident1's GACH's emergency room (ER) Record dated 11/4/2025, the GACH ER record indicated Resident 1 was found at local restaurant located approximately one mile away from the facility. Resident 1 complained of shortness of breath while in the restaurant. 911 was called and Resident 1 was transported to a GACH. The GACH emergency room Record indicated Resident 1 arrived at GACH at 11:04 p.m., experienced a cardiac arrest and was pronounced dead on 11/4/2025 at 11:39 pm. During an observation on 11/07/2025 at 6:55 a.m. at the facility entrance, the front door was observed propped open with a box of gloves, and the lobby area was unsupervised, with no staff present to monitor the entrance. During a concurrent observation and interview on 11/07/2025 at 7:02 a.m. at the facility's front entrance, Certified Nursing Assistant (CNA) 1 stated the front door should remain closed, as it locks from the outside and was equipped with a doorbell. CNA 1 stated that Station 1 staff were responsible for opening the door for staff entering the facility. CNA 1 stated a box of gloves had been used to prop the door open so that staff would not have to repeatedly open it for incoming facility staff. CNA 2 further stated that leaving the door open without supervision posed a risk, as residents could potentially exit the facility unsupervised, and unauthorized individuals could enter, creating significant safety concern. During an observation on 11/07/2025 at 7:10 a.m., the emergency exit door located in Station Three was observed alarming. The alarm continued to sound until 7:18 a.m., when Certified Nursing Assistant (CNA) 2 arrived and turned off the alarm and secured the door. During an observation on 11/07/2025 at 7:17 a.m. at Nursing Station 3, CNA 2, CNA 3, and Licensed Vocational Nurse (LVN) 1 were observed sitting at the nursing station and conversing with one another, while the emergency exit door alarm on Station Three continued to sound. During an interview on 11/07/2025 at 7:20 a.m., with CNA 2, CNA 2 stated he did not have the key to turn off the emergency door alarm and only Licensed Vocational Nurses (LVNs) were authorized to do so. CNA 2 stated CNAs were not permitted to touch the alarms. CNA 2 stated a resident could have pushed the door open and exited the facility, as the door locks from the outside and alarms when opened from the inside. During an interview on 11/07/2025 at at 7:25 a.m., with CNA 3, CNA 3 stated LVNs were responsible for silencing the emergency exit door alarms because they have the keys. CNA 3 stated she could not locate the LVN to inform her about the alarm sounding. CNA 3 stated she should have checked the door herself to determine the cause of the alarm, as a resident could have exited or an unauthorized person could have entered the facility. CNA 3 stated leaving the door unsecured could pose a serious safety risk. During an interview on 11/07/2025 at 7:32 a.m., with LVN 1, LVN 1 stated he heard the alarm but was busy with preparing staff's schedule and assumed that a CNA would respond to the door. LVN 1 stated she forgot she had the key to silence the alarm. LVN 1 stated she should have checked the door immediately to ensure that no residents had left the facility. During an interview on 11/7/2025, at 8:00 a.m., with the Receptionist the Receptionist stated the front door of the facility was typically open around 7:45 a.m. and closed around 6:30 p.m. The Receptionist stated the door locks from the outside, but can be opened freely from the inside, allowing individuals to exit without restriction. The Receptionist stated there was no alarm system on the front door, however, a doorbell was present. The Receptionist stated that she was aware staff had been propping the front door open with box of gloves in the mornings prior to her arrival. The Receptionist stated she had repeatedly instructed staff to keep the door closed, due to concern for safety. The Receptionist stated the Administrator was aware of this practice, and she believed it was not safe. The Receptionist stated on 11/4/2025, at approximately 10:00 055559 Page 9 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few a.m., she observed Resident 1 in the lobby, pacing back and forth using an FWW. The Receptionist stated Resident 1 appeared unsteady and had difficulty walking. The Receptionist stated Resident 1 was an elopement risk and should have reported her observation, but she became distracted by a phone call and did not do so. During an interview on 11/07/2025 at 8:50 a.m. with the Maintenance Supervisor (MS), the MS stated the facility has a total of six exit doors. MS stated six exit doors were locked from the outside and always alarmed from the inside. MS stated if any of these doors were opened from the inside, an alarm would sound. MS stated the front door does not have an alarm system installed. During a phone interview on 11/07/2025 at 11:32 a.m. with CNA 4, CNA 4 stated she was responsible for Resident 1 on the night Resident 1 went missing. CNA 4 stated the last time she saw Resident 1 was around 7:30 p.m., at which time Resident 1 was in his bed. CNA 4 stated she believed Resident 1 exited through the front door. CNA 4 stated the front door locks from the outside but can easily be opened from the inside, as there was no alarm system in place. CNA 4 stated because staff were often busy, it was difficult to monitor the front door consistently. During a concurrent interview and record review on 11/7/2025 at 12:03 p.m. with the Physical Therapy Director (PTD), Resident1's Joint Mobility Screening dated 11/04/2025 was reviewed. The PTD stated she had completed the assessment and stated Resident 1 demonstrated full range of motion in both upper and lower extremities. PTD stated Resident 1 was able to walk to the bathroom using a FWW with minimal assistance but required frequent safety cues due to being impulsive while walking. During a concurrent interview and record review on 11/7/2025 at 1:59 p.m. with RNS 1, Resident 1's Elopement Risk assessment dated [DATE] and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 1 stated she had completed the Elopement Risk Assessment for Resident 1. RNS 1 stated that prior to completing the assessment, she interviewed Resident 1 and reviewed Resident 1's GACH 1's record. RNS 1 stated she observed Resident 1 was unresponsive, only answering questions selectively. RNS 1 stated she observed Resident 1's arms were moving erratically, and when asked if he could walk, Resident 1 did not provide a clear yes or no response. RNS 1 stated based on her observations, Resident 1 was non-ambulatory (not walking) and unable to self-propel in a wheelchair. RNS 1 stated that in her assessment, he looked like he could not walk. RNS 1 stated she did not review the PT's notes from GACH 1's, which indicated that Resident 1 was able to ambulate with a FWW with minimal assistance. RNS 1 stated that had she known Resident 1 was ambulatory (able to walk), she would have assessed Resident 1 as high risk for elopement and implemented appropriate interventions to alert staff. RNS 1 stated Resident 1's elopement was avoidable and that staff should have been more attentive to his condition and risk level. During a concurrent interview and record review on 11/8/2025 at 8:22 a.m. with RNS 2 Resident 1's Elopement Risk assessment dated [DATE] and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 2 stated that RNS 1 inaccurately assessed Resident 1 on 11/4/2025 as not being at risk for elopement. RNS 2 stated based on the available information, Resident 1 should have been assessed as high risk for elopement. RNS 2 stated when a resident was identified as high risk for elopement, the facility was expected to implement specific interventions, including placement of an elopement bracelet on the resident, room assignment near the nurses' station, facility-wide staff notification regarding the resident's elopement risk and frequent visual checks, typically every 15 minutes. RNS 2 stated the facility failed Resident 1 by not identifying and addressing his elopement risk appropriately. RNS 2 stated concern about the front door security, stating that when the lobby was closed, the facility relies on Station 1 staff to monitor the front door, even though there was no alarm system to alert staff if someone exits. RNS 2 stated any resident can simply push the door open, and that staff are often too busy providing care to continuously monitor the front entrance. During an interview on 11 /09/2025 at 12:27 p.m., with 055559 Page 10 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 055559 Page 11 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received timely and appropriate medication administration upon admission. This deficient practice resulted in failure to accurately transcribe and process Resident 1's physician orders, resulting in a delay in administering eight prescribed medications for serious medical conditions. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted from GACH 1 to the facility on [DATE] with the diagnosis including acute myocardial infraction (MI-heart attack), presence of coronary angioplasty implant and graft (minimally invasive procedure used to open narrowed or blocked coronary [arteries which surround and supply the heart] arteries), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) chronic obstructive pulmonary disease (COPD-lung disease) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's Order Summary Report dated 11/07/2025, the Order Summary Report indicated Resident 1 was to receive the following medications on 11/04/2025 1. Aspirin 81miligrams (mg unit of measurement) once a day for cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain). 2. Atorvastatin 80 mg give at bedtime for hyperlipidemia ( high cholesterol).3. Carvedilol 3.125 mg twice a day for hypertension (high blood pressure). 4. Clopidogrel 75 mg once a day for deep vein thrombosis (DVT- blood clot).5. Levetiracetam 500 mg every 12 hours (hrs.) for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).6. Olanzapine 10 mg at bedtime for psychotic behavior.7. Pantoprazole 40 mg in the morning for gastroesophageal reflux disease (GERD- burning sensation in the chest heartburn). 8. Spironolactone 25 mg once a day for heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen).During a phone interview on 11/07/2025 at 11:18 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she had cared for Resident 1 on 11/03/2025 and first saw the resident around 11:30 p.m. in bed. LVN 4 stated she was unable to locate Resident 1's admission packet (hospital orders) and therefore did not input any of the resident's medications into the electronic system.During an interview on 11/07/2025 at 1:59 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that she began entering Resident 1's medication orders into the electronic system on 11/04/2025. RNS 1 stated that Resident 1 had arrived at the facility on 11/03/2025, but no arrival time was documented. RNS 1 stated that the LVN should have entered the medication orders upon the resident's arrival. RNS 1 stated that this delay resulted in a delay in care for Resident 1.During an interview on 11/09/2025 at 12:27 p.m., with the Administrator (ADM), the ADM stated that medications should be ordered immediately upon a resident's arrival to ensure timely care and to meet the resident's medical needs.During a review of the facility's policy and procedure (P&P) titled Medication ordering and receiving from pharmacy the P&P indicated Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Medication orders are written on a medication order form (i.e. telephone order sheet, reorder form, etc.) provided by the pharmacy or written in the chart by the physician or authorized personnel and transmitted to the pharmacy. The written entry includes:a. Date orderedb. Whether the order is new or a repeat order (refill). If the order is a repeat order (refill), include the prescription number.c. Resident's name and other identifying information, when necessaryd. Medication name and strength, when indicatede. Directions for use, if a new order, or direction changes to a previous order with indication as to whether a new supply 055559 Page 12 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

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 055559 Page 13 of 14 055559 11/09/2025 Bay Crest Care Center 3750 Garnet Street Torrance, CA 90503

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 055559 Page 14 of 14