Inspection·December 12, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete noncompliance with nursing care, a tendency to sleep sitting at the edge of the bed, and going to the bathroom without calling for assistance. The Care Plan's interventions included placing Resident 4's call light within reach. During a concurrent interview and observation on 10/10/2025, at 3:10 p.m., Resident 4 was observed sitting on the edge of her bed. Resident 4's call light was observed out of Resident 4's reach, sitting on the bedside table of B bed. Resident 4 stated she had been looking for her call light but could not find it. Resident 4 stated when she needed help, she would yell for a nurse because she had no other way to request assistance. Resident 4 stated she could hear someone across the hall yelling, which happened often and disrupts her rest. Resident 4 stated the yelling probably was because a resident didn't have their call light either and she was frustrated because she didn't have her call light and because her neighbor yelled for a nurse all the time. During a concurrent interview and observation on 10/10/2025, at 3:35 p.m., CNA 2 was observed in Resident 4's room, Resident 4 was overheard asking CNA 2, where was her call light? CNA 2 looked for Resident 4's call light and located it on the bedside table of B' Bed. (Resident 4 was in C bed). CNA 2 stated that Resident 4's call light was not in Resident 4's reach, someone must have moved it. CNA 4 stated Resident 4's should have access to her call light so she could ask for assistance, or she might try to get up on her own, fall and get hurt. During an interview on 10/22/2024 at 4:30 p.m., the Director of Nursing (DON) stated staff should make frequent room rounds to ensure residents' call lights were accessible to the residents. The DON stated Residents 3 and 4 were at greater risk for injuries and falls when they could not reach their call lights because they might try to reach for items or get out of bed on their own. During a review of the facility's undated Policy and Procedure (P/P), titled, Answering the Call Light dated 10/24/2024, the P/P indicated the facility ensures timely responses to the residents' requests and needs. The P/P indicated ensure the call light is plugged in and always functioning, ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility . Event ID: Facility ID: 055559 If continuation sheet Page 2 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the responsible Party (RP) for one of three sampled residents (Resident 1) was notified when Resident 1 had a change of condition (COC) This deficient practice resulted in Resident 1's RP visiting Resident 1 at the facility and observing Resident 1 sleepier than usual, but she was unaware that Resident 1 had been given multiple medications that were not his. This deficient practice had the potential for Resident 1's RP to be unable to make decisions regarding Resident 1's care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hemiplegia (total loss of movement and feeling in one side of body) and hemiparesis (one sided weakness) affecting the resident's right side, atrial fibrillation ([a-fib] heart rhythm disorder) and type 2 DM. During a review of Resident 1's History and Physical (H/P), dated 8/10/2025, the H/P indicated Resident 1 does not have the capacity to understand and make decisions but was able to make decisions for activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think and reason) with the ability to understand and be understood by others During a review of Resident 1's Change of Condition (COC) document, dated 10/22/2025, the report indicated Resident 1 received the wrong medication. During an interview on 10/23/2025, at 8:45 a.m., Resident 1 stated on 10/22/2025 he was transported to a GACH because he received the wrong medication. Resident 1 stated yesterday morning (10/22/2025), he was given medication by a new nurse (SN 1). Resident 1 stated SN 1 did not ask what his name was, his birth date nor did she review his medications with him prior to administering them to him. Resident 1 stated he did not remember much of yesterday, his wife was the one that noticed something was wrong him. During a telephone interview on 10/23/2025, at 10:30 a.m., Resident 1 ‘s Responsible Party (RP 1) stated on 10/22/2025 she noticed that Resident 1 was sleepier than usual. RP 1 stated she asked Certified Nurse Assistant (CNA) 1 to take RP 1‘s blood pressure and his blood pressure results were in the 80's or low 90's. RP 1 stated she was concerned because Resident 1 was so sleepy that he would not drink his water and he could not remember if he slept well the night before, which was unusual for him. RP 1 said the DON entered the room around 1 p.m. to assess Resident 1 and that was when she was first notified that Resident 1 had received the wrong medication that morning. During a telephone interview on 10/24/2025, at 2:37 p.m., LVN 1 stated The DON instructed her to complete a COC form and notify Resident 1's RP of the medication error. LVN 1 stated she failed to notify Resident 1's RP of Resident 1's COC because she was focused on monitoring Resident 1 for any changes and forgot to call his RP. During an interview on 10/24/2025, at 4:17 p.m., the DON stated when LVN 1 reported the medication error on 10/22/2025 at approximately 10 a.m., he instructed her to notify Resident 1's RP. The DON stated LVN 1 left work early that day, at approximately 1 p.m., but did not inform him that she had not notified Resident 1's R that he had received wrong medications. During a review of the facility's Policy and Procedure (P/P) titled, Change of Condition, revised 8/25/2021, the P/P indicated the following, the purpose of the policy is to ensure residents, family, legal representatives, physicians are informed of changes to the resident's condition, the facility must inform the resident. and notify, consistent with his authority, the resident's representative where there is. a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications, or the need to alter treatment significantly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 3 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm (a need to discontinue or change an existing form of treatment due to adverse consequences). During a review of the facility's P/P titled, Medication Errors revised 6/28/2022, the P/P indicated upon discovery of an error, notification will be immediately given to the. resident and responsible party. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 4 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 Licensed Vocational Nurse (LVN) 1 provided direct supervision to Student Nurse (SN) 1 on 10/22/2025 when administering scheduled 9 am medications to one of three sampled residents Resident 1) along with not ensuring the five rights of medication administration were abided by. This deficient practice resulted in Resident 1 receiving Valsartan (a medication that lowers the blood pressure), multivitamin and minerals, Guaifenesin (a medication that helps loosen and thin mucus in the throat and chest) extended release ([ER] version of pill where medicine steadily throughout the day in the body), Eliquis (a medication used to prevent blood lots, thin blood), Carvedilol (used to lower the blood pressure and heart rate), Keppra (a medication used to treat seizures), Magnesium Oxide (a mineral supplement which could cause diarrhea, bloating and stomach cramps) in error. This deficient practice resulted in Resident 1 not receiving his prescribed medications; Glipizide (a medication used to treat type 2 diabetes [DM] a disorder characterized by difficulty in b/s control and poor wound healing), Metformin (a medication used to treat high b/s), Baclofen (a medication used to treat tightness and stiffness caused by muscle spasms), vitamin D, Iron, Finasteride (a medication used to treat an enlarged prostate [male organ]) and Lacosamide (a medication used to treat seizures). Resident 1 was subsequently transported to a General Acute Care Hospital (GACH) for monitoring and evaluation resulting in invasive venipunctures ([ blood draw] removing blood from a vein using a needle), unplanned exposure to radiation via an Xray (a medical imaging that uses radiation to create pictures of the inside of the body) and a Computed Tomography ([CT] high power studies that takes multiple x-rays from different angles to create pictures of inside the body) scan. This deficient practice placed Resident 1 at risk for harm, such as allergic reactions, alteration in blood sugar [b/s], bleeding and death.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hemiplegia (total loss of movement and feeling in one side of body) and hemiparesis (one sided weakness) affecting the resident's right side, atrial fibrillation ([a-fib] heart rhythm disorder) and type 2 DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think and reason) with the ability to understand and be understood by others. During a review of Resident 1's Change of Condition (COC) document, dated 10/22/2025, the COC indicated Resident 1 received the wrong medication. During a review of Resident 1's Order Summary Report (Physician's Order), dated 10/22/2025, the Physician' Order indicated to transfer Resident 1 to a GACH emergency room (ER) or further evaluation related to the wrong medication administration. During a review of Resident 1's Nurses Progress Notes, dated 10/22/2025, the Nurse Progress Note indicated Resident 1 was transferred to a GACH via 911 for evaluation. During a review of the GACH ER records dated 10/22/2025, the ER records indicated Resident 1 was admitted to the GACH on 10/22/2025 and presented to the ER for evaluation due to receiving the wrong medications at the skilled nursing facility (SNF) Resident 1 resided at. The ER records indicated Resident 1 underwent blood tests and radiological studies to rule out the risk of bleeding and other adverse drug effects. During an interview on 10/23/2025, at 8:45 a.m., Resident 1 stated on 10/22/2025 he was transported to a GACH because he received the wrong medication. Resident 1 stated yesterday morning (10/22/2025), he was given medication by a new nurse (SN 1). Resident 1 stated SN 1 did not ask what his name was, his birth date nor did she review his medications with him prior to administering them to him. Resident 1 stated he did not remember much of yesterday, his wife was the one that noticed something was wrong him. Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 5 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/23/2025, at 1:30 p.m., the DON stated on 10/22/2025 at approximately 10 a.m., LVN 1 informed him that she was mentoring SN 1 and SN 1 had given Resident 1 the wrong medication. The DON stated LVN 1 reported that Resident 1 received Resident 2's scheduled 9 a.m., medications in error. The DON stated he assessed Resident 1 at approximately 1:30 p.m. and found Resident 1 was sleepy but arousable with his BP was in the 90s. The DON stated he informed the RP that Resident 1 had received several medications in error and the RP insisted that he call 911 to transport Resident 1 to the GACH. The DON stated when EMS arrived to the facility he provided them with a list of medications that Resident 1 received in error. During a telephone interview on 10/23/2025, at 2:18 p.m., SN 1 stated he was allowed to administer medications under the direct supervision of a licensed nurse and on 10/22/2025 he was assigned to shadow LVN 1 during a medication pass. SN 1 stated during the morning of 10/22/2025 he was standing at the medication cart which was located at the doorway of Resident 1 and Resident 2's shared room. SN 1 stated LVN 1 was putting medications in a cup then handed him the cup that had multiple tablets in it. SN 1 stated he was instructed by LVN 1 to give B bed (Resident 1) all the medications that were in the cup. SN 1 stated he went to Resident 1 and proceeded to administer the medications that were in the cup to Resident 1 without LVN 1 present to watch him. SN 1 stated he did not identify Resident 1 by asking his name or verifying Resident 1's identity by picture. During a telephone interview on 10/24/2025, at 1:55 p.m., SN 2 stated on 10/22/2025, she was assigned to shadow LVN 1 during a medication pass. SN 2 stated LVN 1 often remained at the doorway near the cart and did not accompany her (SN 1) to the resident's bedside while she administered medications to the residents. SN 2 stated LVN 1 often remained at the medication cart in the doorway and did not accompany her to the bedside when administering medications. During a telephone interview on 10/24/2025, at 2:37 p.m., LVN 1 stated on 10/22/2025 she was assigned to mentor three nursing students. LVN 1 stated at approximately 9 a.m., she prepared medications with SN 1 to administer to Resident 2 and handed medications that were in a medication cup to SN 1. LVN 1 stated she was standing at the medication cart in the doorway of Resident 1 and Resident 2's shared room and planned to watch SN 1 administer the medication to Resident 2 but turned her back to SN 1 to start preparing Resident 1's medications with SN 2. LVN 1 stated she did not accompany SN 1 to Resident 2's bedside to ensure the medications were administered to him correctly by utilizing the five rights of medication administration: the right patient, the right medication, the right time, the right dose and the right route. LVN 1 stated by failing to supervise SN 1 and failing supervise SN 1 during Resident 1's medication pass and not utilizing e the five rights of medication administration that caused Resident 1 to receive numerous medications in error placing Resident 1 at risk for severe injury from side effects and death. During an interview on 10/24/2025, at 4:17 p.m., the DON stated all licensed nurses in the facility were trained on how to mentor nursing students. The DON stated, per the agreement with the Nursing School, students could administer medications to the residents under the direct supervision of a licensed nurse. The DON stated LVN 1 should have accompanied SN 1 during the medication pass to ensure the medications were properly administered by utilizing the five rights of medication administration; the right resident, right medication, right route, right time, and right dose).The DON stated licensed nurses should not hand medication they prepared for administration to anyone and allow them to administer the medication to a resident out of their presence and should observe the complete administration of the medication before leaving the resident. The DON stated the failure of LVN 1 to follow the correct medication administration steps lead to Resident 1 receiving the wrong medications and placed Resident 1 at risk for adverse reactions which led to Resident 1's COC and transfer to a GACH for evaluation and treatment. During a telephone interview on 10/27/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 6 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete at 9:36 a.m., the facility's Consultant Pharmacist (CP) stated that five rights of medication administration (right patient, right med, right time, right dose, right route) should be followed when administering medications to residents. The CP stated prior to medication administration the LVN must ensure the identity of the resident by using at least two (2) identifiers, such as: name, picture, wrist ID band, to make sure medications to be administered were for the right resident. The CP stated LVN 1 failed to follow 5 rights of medication administration and failed to follow facility medication administration guidelines, by failing to ensure the right medications were administered to the right resident. The CP stated these were considered significant medication errors. The CP stated the LVN 1 failed to supervise the student during Resident 1's medication pass and this cause harm to Resident. During a review of the facility's Job Description titled, Licensed Practical /Vocational nurse revised May 5/2022, the Job description indicated general duties and responsibilities included the following: provides nursing services to residents in accordance with scope of practice, facility policies, and professional standards of care. During a review of the facility's Policy and Procedure (P/P) titled, Administering Medications, revised April 4/2019, the P/P indicated.the individual administering medications verifies the resident's identity before giving the resident his or her medications, methods of identifying the resident include , checking the identification band, checking photograph attached to medical record and if necessary verifying resident identification with facility personnel, the individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before giving the medication. Event ID: Facility ID: 055559 If continuation sheet Page 7 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 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 Licensed Vocational Nurse (LVN) 1 provided direct supervision to Student Nurse (SN) 1 on 10/22/2025 when administering 9 a.m., scheduled medications to one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving Valsartan (a medication that lowers the blood pressure), multivitamin and minerals, Guaifenesin (a medication that helps loosen and thin mucus in the throat and chest) extended release ([ER] version of pill where medicine steadily throughout the day in the body), Eliquis (a medication used to prevent blood lots, thin blood), Carvedilol (used to lower the blood pressure and heart rate), Keppra (a medication used to treat seizures), Magnesium Oxide (a mineral supplement which could cause diarrhea, bloating and stomach cramps) in error. This deficient practice resulted in Resident 1 not receiving his prescribed medications; Glipizide (a medication used to treat type 2 diabetes [DM] a disorder characterized by difficulty in b/s control and poor wound healing), Metformin (a medication used to treat high b/s), Baclofen (a medication used to treat tightness and stiffness caused by muscle spasms), vitamin D, Iron, Finasteride (a medication used to treat an enlarged prostate [male organ]) and Lacosamide (a medication used to treat seizures). Resident 1 was subsequently transported to a General Acute Care Hospital (GACH) for monitoring and evaluation resulting in invasive venipunctures ([ blood draw] removing blood from a vein using a needle), unplanned exposure to radiation via an Xray (a medical imaging that uses radiation to create pictures of the inside of the body) and a Computed Tomography ([CT] high power studies that takes multiple x-rays from different angles to create pictures of inside the body) scan. This deficient practice placed Resident 1 at risk for harm, such as allergic reactions, alteration in blood sugar [b/s], bleeding and death.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hemiplegia (total loss of movement and feeling in one side of body) and hemiparesis (one sided weakness) affecting the resident's right side, atrial fibrillation ([a-fib] heart rhythm disorder) and type 2 DM. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 1 had moderate cognitive impairment (ability to think and reason) with the ability to understand and be understood by others. During a review of Resident 1's Change of Condition (COC) document, dated 10/22/2025, the COC indicated Resident 1 received the wrong medication. During a review of Resident 1's Order Summary Report (Physician's Order), dated 10/22/2025, the Physician' Order indicated to transfer Resident 1 to a GACH emergency room (ER) or further evaluation related to the wrong medication administration. During a review of Resident 1's Nurses Progress Notes, dated 10/22/2025, the Nurse Progress Note indicated Resident 1 was transferred to a GACH via 911 for evaluation. During a review of the GACH ER records dated 10/22/2025, the ER records indicated Resident 1 was admitted to the GACH on 10/22/2025 and presented to the ER for evaluation due to receiving the wrong medications at the skilled nursing facility (SNF) Resident 1 resided at. The ER records indicated Resident 1 underwent blood tests and radiological studies to rule out the risk of bleeding and other adverse drug effects. During a review of the facility's Cell Phone Log, dated 10/22/2025, the Cell Phone Log indicated the following text messages between LVN 1 and Resident 1's physician: 1. 9:52 a.m. - a text message was sent to Resident 1's physician indicating Resident 1 received the wrong medications 2. 9:56 a.m. - a text message from Resident 1's physician indicating type it out please, what was the medication error? 3. 9:58 a.m. - a text message from Resident 1's physician indicating, Resident 1 received medications that were for another resident (Resident 2). I am trying to send a list of medications, but the internet Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 8 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some went down, I am unable to send his list of medications to compare to the ones he received. 4. 10:27 a.m. - a text message Resident 1's physician indicating to monitor blood pressure for 72 hours, bleeding precautions for 10 days, let the Director of Nursing (DON) and Administrator (ADM) know of the medication error which can be fatal, needs to be logged via appropriate channels, do not let it happen again, I cannot see pictures, type out medication names and dosing please. 5. 11:27 a.m. - a text message was sent to Resident 1's physician indicating Resident 1 received the following medications: Valsartan 40 mg, Multivitamin and minerals, Guaifenesin ER 600 mg, Eliquis 5 mg, Carvedilol 6.25 mg, Keppra 250 mg, Mag Ox 400 mg. 6. 11:30 a.m. - a text message sent to Resident 1's physician indicating Resident 1's prescribed medications were held; Glipizide 5 mg, Metformin 100 mg, Baclofen 10 mg, Vitamin D, Iron, Finasteride 5 mg and Lacosamide 50 mg. 7. 2:01 p.m. - a text message sent to Resident 1's Physician indicating can we send him (Resident 1) to the ER for evaluation, I am very concerned? blood pressure 96/65, Resident 1 has been sleeping (more) than usual. 8. 2:15 p.m. - a text message from Resident 1's physician indicated who, we need names. 9. 2:16 p.m. - a text message sent to Resident 1's physician indicated Resident 1 received the wrong meds. 10. 2:16 p.m. - a text message from Resident 1's physician indicated, send Resident 1 to the GACH. During an interview on 10/23/2025, at 8:45 a.m., Resident 1 stated on 10/22/2025 he was transported to a GACH because he received the wrong medication. Resident 1 stated yesterday morning (10/22/2025), he was given medication by a new nurse (SN 1). Resident 1 stated SN 1 did not ask what his name was, his birth date nor did she review his medications with him prior to administering them to him. Resident 1 stated he did not remember much of yesterday, his wife was the one that noticed something was wrong him. During a telephone interview on 10/23/2025, at 10:30 a.m., Resident 1 ‘s Responsible Party (RP 1) stated on 10/22/2025 she noticed that Resident 1 was sleepier than usual. RP 1 stated she asked Certified Nurse Assistant (CNA) 1 to take RP 1‘s blood pressure and his blood pressure results were in the 80's or low 90's. RP 1 stated she was concerned because Resident 1 was so sleepy that he would not drink his water and he could not remember if he slept well the night before, which was unusual for him. RP 1 said the DON entered the room around 1 p.m. to assess Resident 1 and that was when she was first notified that Resident 1 had received the wrong medication that morning. During an interview on 10/23/2025, at 1:30 p.m., the DON stated on 10/22/2025 at approximately 10 a.m., LVN 1 informed him that she was mentoring SN 1 and SN 1 had given Resident 1 the wrong medication. The DON stated LVN 1 reported that Resident 1 received Resident 2's scheduled 9 a.m., medications in error. The DON stated he assessed Resident 1 at approximately 1:30 p.m. and found Resident 1 was sleepy but arousable with his BP was in the 90s. The DON stated he informed the RP that Resident 1 had received several medications in error and the RP insisted that he call 911 to transport Resident 1 to the GACH. The DON stated when EMS arrived to the facility he provided them with a list of medications that Resident 1 received in error. During a telephone interview on 10/23/2025, at 2:18 p.m., SN 1 stated on he was allowed to administer medications under the direct supervision of a licensed nurse and on 10/22/2025he was assigned to shadow LVN 1 during a medication pass. SN 1 stated during the morning of 10/22/2025 he was standing at the medication cart which was located at the doorway of Resident 1 and Resident 2's shared room. SN 1 stated LVN 1 was putting medications in a cup then handed him the cup that had multiple tablets in it. SN 1 stated he was instructed by LVN 1 to give B bed (Resident 1) all the medications that were in the cup, two at a time with a spoon with water. SN 1 stated he went to Resident 1and proceeded to administer the medications that were in the cup to Resident 1 without LVN 1 present to watch him. SN 1 stated he did not identify Resident 1 by asking his name or verifying Resident 1's identity by picture. SN 1 stated after administering medications to Resident 1, he left the room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 9 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some about 20 minutes later he returned to the medication cart and LVN 1 handed him another cup with medications in it that were crushed and mixed in applesauce and instructed him to give the medications that were in the cup to the resident in B bed. SN 1 stated he asked LVN 1 to clarify who he was to administer the medications to and LVN 1 repeated again the resident in B bed. SN 1 stated he informed LVN 1 that he had already given medications to the resident in B bed per her (LVN 1's) instructions. SN 1 stated that was when LVN 1 informed him that he had administered Resident 2's medications to Resident 1 in error. SN 1 stated LVN 1 notified the DON and Resident 1's physician of the medication error. SN 1 stated he did not follow his school policy nor the facility's policy and placed Resident 1 at risk for harm and possible death. During a telephone interview on 10/24/2025, at 1:27 p.m., SN 1 stated he became complacent when administering residents their medications, and it was not unusual for him to do so without the LVN 1 present when he gave residents their medication. SN 1 stated it was LVN 1's practice to give student nurses medications to administer while she stood at the medication cart. During a telephone interview on 10/24/2025, at 1:55 p.m., SN 2 stated on 10/22/2025, she was assigned to shadow LVN 1 during a medication pass. SN 2 stated LVN 1 often remained at the doorway near the cart and did not accompany her (SN 1) to the resident's bedside while she administered medications to the residents. SN 2 stated LVN 1 refers to residents by their bed assignment (e.g., A or B bed), which she found confusing and would often prepared medications for another resident while she talked to staff or other residents who were at the medication cart. SN 2 stated she should not have administered medications to any residents without direct supervision from a licensed nurse. During a telephone interview on 10/24/2025, at 2:37 p.m., LVN 1 stated on 10/22/2025 she was assigned to mentor three nursing students. LVN 1 stated at approximately 9 a.m., she prepared medications with SN 1 to administer to Resident 2 and handed medications that were in a medication cup to SN 1. LVN 1 stated she was standing at the medication cart in the doorway of Resident 1 and Resident 2's shared room and planned to watch SN 1 administer the medication to Resident 2 but turned her back to SN 1 to start preparing Resident 1's medications with SN 2. LVN 1 stated when SN 1 returned to the medication cart she informed him that they would next administer Resident 1's medications which she had already crushed and placed in apple sauce in a medication cup. LVN 1 stated SN 1 informed her that he had already given Resident 1 his medication and that was when she realized SN 1 had administered Resident 2's medication in error to Resident 1. LVN 1 stated she notified the DON and Resident 1's physician of the medication error. LVN 1 stated her not supervising SN 1 during a medication pass, placed Resident 1 at risk for adverse effects and possible death. During a telephone interview on 10/24/2025, at 2:25 p.m., Resident 1's Physician stated he received a text message from facility staff indicating Resident 1 received medications in error, with a list of the medications Resident 1 had been given. Resident 1's Physician stated based on the text message of medications Resident 1 received in error, the nursing staff placed Resident 1 at risk for a decline in health related to the potential side effects of medications such as potential for allergic reactions, low blood pressure, changes in the level of consciousness, the potential for bleeding, heart rate changes and alterations in blood sugar levels. During an interview on 10/24/2025, at 4:17 p.m., the DON stated all licensed nurses in the facility were trained on how to mentor nursing students. The DON stated, per the agreement with the Nursing School, students could administer medications to the residents under the direct supervision of a licensed nurse. The DON stated LVN 1 should have accompanied SN 1 during the medication pass to ensure the medications were properly administered by utilizing the five rights of medication administration; the right resident, right medication, right route, right time, and right dose).The DON stated licensed nurses should not hand medication they prepared for administration to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055559 If continuation sheet Page 10 of 11 Printed: 05/15/2026 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 055559 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete anyone and allow them to administer the medication to a resident out of their presence and should observe the complete administration of the medication before leaving the resident. The DON stated the failure of LVN 1 to follow the correct medication administration steps lead to Resident 1 receiving the wrong medications and placed Resident 1 at risk for adverse reactions which led to Resident 1's COC and transfer to a GACH for evaluation and treatment. During a review of the facility's Policy and Procedure (P/P) titled, Administering Medications revised 4/2019, the P/P indicated the following. , the individual administering medications verifies the resident's identity before giving the resident his or her medications, methods of identifying the resident include, checking the identification band, checking photograph attached to the medical record and if necessary verifying resident identification with facility personnel, the individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, right time and right method (route) of administration before given the medication. During a review of the Nursing School's updated Clinical Objective Guidelines/Contract with the SNF, the Guidelines /Contract indicated the students perform procedures according to the facility's policy manual, perform medication administration safely under supervision, including correct dosage calculation and the right of medication administration. Event ID: Facility ID: 055559 If continuation sheet Page 11 of 11