Bay Crest Care Center

In the surveyor’s words

From the most serious findings on record at Bay Crest Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 9, 2025

  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 (FWW- assistive 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. […]

• Immediate jeopardy, isolatedF678Aug 19, 2025

  Based on interview, and record review, the facility failed to ensure, when a resident was found unresponsive and pulseless (no detectable heart beat), the nursing staff immediately initiated basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) by performing cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), checked Resident 1's pulse when on [DATE] at approximately 4:50 a.m. […]

• Immediate jeopardy, isolatedF757May 2, 2023

  Based on interview and record review, the facility failed to ensure a resident, who was receiving medications that act as a central nervous system ([CNS] a complex of nerve tissues that controls the activities of the body) depressant (a type of medication which slows down brain activity and causes the muscles to relax), including Quetiapine (Seroquel), an antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]), Gabapentin [(Neurontin) an anti-convulsant medication used to prevent or treat seizures pain caused by nerve damage] and Cymbalta [(Duloxetine) an anti-depressant used to treat tingling pain associated with nerve damage] in combination with Oxycodone (an opioid [medication used to treat moderate to severe pain], was prescribed and used as… […]

• Immediate jeopardy, isolatedF600Jan 3, 2023

  Based on interview and record review, the facility failed to ensure residents were free from verbal abuse, including disparaging (opinion of little worth) and derogatory (critical or disrespectful attitude) words and disrespect for one of three sampled residents (Resident 24) by Licensed Vocational Nurse (LVN) 34. The facility failed to: 1. Ensure LVN 34 did not use profanity and disparaging words about and towards Resident 24 after Resident 24 continue to complain for over four months (8/2022-12/2022) of verbal abuse and mistreatment. 2. Ensure LVN 34 did not use profanity to describe Resident 24 during morning huddles (a brief meeting of nursing staff, regarding residents' care) date and time unknown, while in the facility's hallway, in the earshot of other residents and staff. 3. […]

• Actual harm, isolatedF689Oct 17, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident, who had diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body) and generalized muscle weakness, did not sustain a second-degree burn (a burn injury that damages the outer layers of the skin [epidermis] and/or part of the underlying layer of the skin [dermis] but does not penetrate deeper into the subcutaneous tissue (the deepest layer of the skin beneath the epidermis and dermis) to his left thigh while using an egg cooker in his room for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 did not have in his possession and use an unauthorized appliance (egg cooker) in his room. 2. […]