Bellflower Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their ice machine - used to produce ice for resident distribution and consumption - was clean for safe and sanitary operation. This failure had the potential to result in at least 50 out of 56 residents in the facility suffering waterborne illness, increasing the risk for negative outcomes such as nausea, vomiting, diarrhea, and dehydration.

Inspectors wroteBased on interviews and record review, the facility failed to follow their Quality Assurance (QA) /Quality Assurance and Performance Improvement (QAPI]-a data driven proactive approach to improvement used to ensure services are meeting quality standards) to develop a corrective action plan or performance activities to address problems and opportunities for improvement. This had the potential to result in unsafe practices and harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of eight sampled residents (Resident 53). This failure had the potential to prevent Resident 53 from receiving necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or responsible party ([RP] individual that exercises ultimate control, management, or decision-making authority over a business, asset, or legal obligation) had the opportunity to formulate an advance directive for three of four sampled residents (Resident 1, Resident 6, and Resident 25). This deficient practice had the potential to violate the resident's right to be fully informed of the option to formulate their advance directives and cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 8 and Resident 42) were provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN - written notice issued by the facility to inform the resident of the cost of services that Medicare [federally funded health insurance for individuals aged 65 or older] may not cover and the reason why) in a manner the resident's understood. This deficient practice had the potential to result in violating the residents' rights to appeal the Medicare decision and cause financial burden on Resident 8 and Resident 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, monitor, and document the use of abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) to prevent the resident from pulling out the gastrostomy tube ([G-tube]- a tube inserted through the belly that brings nutrition directly to the stomach) for one of eight sampled residents (Resident 7). These failures had the potential to result in entrapment, skin injury/breakdown, and compromised circulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate resident assessments and the status were reflected on medical records for one of three sampled residents (Resident 7) by failing to ensure the assessment entries on the Minimum Data Set (MDS-a resident assessment tool) for abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) that was a physical restraint (any manual method, physical/mechanical device, or medication used to intentionally limit a patient's movement, freedom, or normal access to their body) was accurately reflected and documented. This failure had the potential to result in a negative effect on Resident 7's plan of care and delivery of necessary services, care, and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of eight sampled residents (Resident 5 and Resident 7) by failing to:A. Develop a comprehensive care plan for Gentamicin (medication to treat severe bacterial infections) for Resident 5. B. Implement a comprehensive person-centered care plan for abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) use for Resident 7. These failures had the potential to result in Resident 5 and Resident 7's needs not being met, affecting the residents' well-being, and poor patient outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was provided with a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) and language translating service with the language that the resident was able to understand for one of eight sample residents (Resident 58). These failures had the potential to result in preventing Resident 58 from communicating with the staff and had the potential to delay receiving appropriate care/treatment and safety for Resident 58.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store medications safely in a locked crash cart (a supply cart stocked with equipment and medications used for emergency situations) located by Nursing station 1. This had the potential to result in adverse medication effects, medication tampering and medication theft.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was palatable (food or drink that is pleasant, savory, or agreeable to the taste) and/or at the preferred temperature for three of 54 sampled residents (Resident 19, Resident 60, and Resident 53). This failure had the potential for residents' poor meal intake and which could lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow their antibiotic stewardship policy for one of three sampled residents (Resident 5) when the facility did not inform the physician when Resident 5, who was prescribed gentamicin (antibiotic to treat bacterial infections) eye drops did not meet McGeer's criteria (criteria used to detect infections based on symptoms and laboratory values). This resulted in Resident 5 receiving inappropriate antibiotic eye drops and the potential to develop antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to educate and offer the COVID-19 vaccination for the 2025-2026 respiratory season for two of five sampled staff (Physician 1 and Physician 2). These failures had the potential to result in spreading the COVID-19 virus throughout the facility.

Inspectors wroteBased on observation. interview and record review, the facility failed to implement infection control measures by failing to:A. Ensure implementing the water management plan (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) by monitoring and documenting control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limit (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably). B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Jello items were stored and maintained at the required temperature of 41-degree Fahrenheit (a temperature scale, range for cold food is below 41 degrees). This failure had the potential to result in food spoilage, compromised taste for residents as proper temperature control is essential to ensure food safety and quality.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, thereby affecting 47 out of 47 residents, failed to identify and implement corrective action to the systemic problems identified: a. Ensure medication parameters are followed when administering medication to residents b. Ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents are assessed before departing for dialysis and after residents return from outpatient dialysis. c. Ensure the kitchen store, prepare and distribute food in accordance with professional standards for food service safety. These deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). This deficient practice had the potential of medication error and/or narcotic diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 15) during the use of an abdominal binder (a wide belt that provides light compression around the stomach) placed over Resident 15's a gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This deficient practice had the potential to place the resident on unnecessary restraints.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled resident's (Resident 37) care plans were reviewed and updated on a quarterly basis. This deficient practice had the potential to result in poor quality of care and a delay in care and services.

Inspectors wroteBased onobservation, interview and record review, the facility failed to 1. Ensure nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). These deficient practices had the potential of medication error and/or narcotic diversion. 2. Ensure one of one sampled residenst (Resident 48) had a urology (a medical specialty that focuses on the diagnosis, treatment, and prevention of diseases and disorders related to the urinary system) consult and received services to meet professional standards of practice. These failures had the potential for Resident 48's penile (located on the penis) open wound to get infected.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of two sampled residents' (Resident 5) foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your) drainage bag was changed as ordered. This deficient practice had the potential to result in complications that can negatively affect the resident's wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility did not provide care and services consistent with professional standards of practice to three of three residents (Resident 5, 30, 49) receiving supplemental oxygen (element essential for life) when the facility failed to: a. Ensure Resident 5 had visible signage warning others oxygen was in use to prevent hazardous practices. b. Ensure Resident 30 and 49's nasal canula (device that delivers oxygen through the nostrils) was labeled with a date to ensure it was changed timely. c. Ensure Resident 30's oxygen use was being documented in the Medication administration record. These deficient practices had the potential to result in unsafe and unsanitary administration of oxygen in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three Residents on hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) , received dialysis care and services based on professional standards (Resident 17, 27, and 113). The facility failed to: a. Ensure staff assessed Resident 113 prior to sending Resident 113 to dialysis. b. Ensure Resident 17 had equipment and supplies necessary to manage emergencies such as bleeding at the bedside. c. Ensure staff assessed Resident 27 and 113 after the residents returned from the dialysis center. These deficient practices had the potential to result in undetected complications from dialysis, or delayed treatment of complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three Licensed Vocational Nurse (LVN 9 ) had the specific competencies and skills sets necessary to care for residents by failing to ensure LVN 9's SNF (Skilled Nursing Facility) Licensed Nurse Orientation Annual Competency checklist (a systematic evaluation of nursing staff's competency levels in various areas of practice) was up to date. This deficient practice had the potential for residents not to receive appropriate nursing services and care which had the potential for injury to residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a facility policy that matched the facility's current method of documentation, specifically in the relations to medication administration record. This deficient practice had the potentials of inaccurate records, drug loss and/or diversion.

Inspectors wroteBased on interview and record review, the facility failed to hold (not administer) the hypertensive medications (drugs used to treat high blood pressure - condition where the force of blood against the artery walls is too high) for two of three residents (Resident 27 and 112) when the residents blood pressures were below given parameters (sets the condition of providing the medication). This deficient practice had the potential to result in hypotension (condition where the blood pressure falls below normal levels) which can cause fainting or dizziness because the brain does not receive enough blood.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure active medications for current residents would not be stored in a cabinet labeled for discontinued medicines. 2. Ensure multiple dosed medication container had an open date and outdated medications would not be stored in the medication cart. These deficient practices had the potentials of medication errors, delay in receiving medications, and/or receiving outdated medications.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled resident's (Resident 37) lab test was completed timely. This deficient practice resulted in a delay of care that had the potential to result in a continued undiagnosed problem that may be harmful for Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Label food items properly. -One opened bottle of 'Thick and Easy' (thickener-a substance which can increase the viscosity of a liquid without substantially changing its other properties) -Two cups of chicken noodle soup -One bag of Seven Zucchinis -Two bunches of Celery -Four lettuces and the Five tomatoes in one container -One bag of cookie dough b. Remove expired items. -Diabetisource AC (a tube feeding formula) -Two bags of bread c. Test and document the concentration of the sanitizing solution and dish machine prior to use. These failures had the potential to result in contamination, or improper sanitation, compromising resident safety, infection control and food borne illness.

Inspectors wroteBased on interview, and record review, the licensed nursing staff failed to maintain and complete accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 27) by failing to: 1. Ensure Resident 27's Dialysis (mechanical removal of waste from the body due to kidney failure) Communication Record DCR (a medical document about a patient's dialysis treatment) was completed. 2. Ensure Licensed Vocational Nurse (LVN) 8, did not falsify Resident 27's Dialysis Communication Record for dates 1/23/2025, 1/28/2025, 2/4/2025 and 2/11/2025 when he (LVN 8) documented about Resident 8 even though he (LVN 8) was not working on those days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure Resident 7's, foley catheter ( a thin, flexible tube inserted into the bladder [an organ that stores urine] to drain urine) was not touching the floor. b. Ensure facility staff used the correct Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) when caring for one of two sampled residents (Resident 15) that was on Enhanced Barrier Precautions (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs)) and not performing hand hygiene prior to entering room. c. Ensure the facility staff had access to PPE d. Conduct annual Legionella (a severe form of lung infection that causes lung inflammation caused by bacteria) facility risk assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and monitor the immunization (a process whereby a person is made resistant to a disease through medication administration) status for the Influenza (flu: a contagious respiratory illness) and Pneumococcal (bacterial infection that causes serious lung infections) vaccinations (medication to prevent a particular disease) for one of five sampled residents (Resident 9). This deficient practice resulted in Resident 9's medical records being incomplete.

Inspectors wroteBased on interview and record review, the facility failed to involve one of three sampled resident's (Resident 26) in the resident's initial Interdisciplinary Team (IDT-team of health care professionals that work together toward and prioritize the resident 's needs) care conference. This deficient practice violated Resident 26's rights to be informed and the right to participate in resident's plan of care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of two sampled residents (Resident 37) addressing Resident 37's anticoagulant (medications that prevent blood from clotting) use. This deficient practice had the potential to result in poor quality of care and a delay of care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident's (Resident 5) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration. This deficient practice violated Resident 5's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for negative health outcomes such as being hospitalized due to COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 20 of 29 resident rooms (Rooms 1 to 7, 11 to 14, 19, 23-29) met the requirements of 80 square feet for each resident in multiple resident bedrooms. The 20 rooms consisted of two beds in each bedroom. This deficient practice had the potential to limit space to provide nursing care, and limit privacy for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to store food with open date (date food package was opened for use) label and food expiration date. This practice put the facility residents at risk for infection by ingesting expired foods and can result in foodborne illnesses and symptoms such as nausea, vomiting, stomach cramps, and diarrhea. The expired foods are at risk for decreased flavor and taste.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs three of 11 sampled residents (Resident 29, 32 and 202): 1. Resident 29 and Resident 32 did not receive medication at the scheduled time and with food as ordered by the physician. 2. Resident 202 received a crushed enteric coated medication. These deficient practices had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure they were free of medication error rate of five (5) percent (%) or greater as evidenced by the identification of three (3) medication errors out of 29 opportunities for errors, to yield a facility medication error rate of 12 % for three of 11 sampled residents (Residents 29, 32, and 202). 1. Resident 202 receive a crushed extended release (ER-designed to slowly release a drug in the body over an extended period of time especially to reduce dosing frequency) medication administration of metoprolol succinate (medication for high blood pressure) 2. During medication administration of metoprolol tartrate (medication to manage high blood pressure) for Resident 32 and metformin HCL (medication used to treat diabetes [abnormal sugar]) for Resident 29. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their infection control policy for five out of 29 sampled residents (14, 32, 40, 153, and 202) by failing to: A: Properly put on personal protective equipment (PPE, equipment used to prevent or minimize exposure to hazards) upon entering Resident 153's contact isolation room. B. Ensure oxygen tubing (plastic tubing applied to the nostrils that delivers life sustaining gases) was not on the ground for Resident 14. c. Disinfect the blood pressure cuff (tool used to measure blood pressure) after each use for Residents 32, 40, and 202.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the dignity of one out of 29 sampled residents (Resident 1) by not providing a dignity bag (conceals the urinary drainage bag [a bag that collects urine] from public view to maintain the residents' dignity) over the urinary catheter bag. This deficient practice had the potential to compromise Resident 1's privacy and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the urine in the foley catheter tubing (a plastic device inserted inside the body to drain urine from the bladder [an organ that is part of the urinary system] into an outside bag) for sediments and cloudiness for one of two sampled residents (Resident 8). Resident 8 had an indwelling foley catheter with noticeable sediment (accumulation of white blood cells) and cloudiness in the urine tubing. This deficient practice placed Resident 8 at risk for a urinary tract infection ([UTI] when bacteria enter the urinary system and infect the urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 14 and Resident 103) received respiratory care consistent with professional standards of practice when: 1. Resident 14's oxygen (life sustaining gas in air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change to be used as reference for changing humidifier bottles every seven days. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 14 . 2. Resident 103's Bilevel positive airway pressure (BIPAP - a device that helps a patient breath) machine was not set up for Resident 103's use, as ordered by physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 29 resident rooms (Rooms 2, 4, 5, 7, 11, 12, 13, 14, 20, 26, 27) met the requirements of 80 square feet for each resident in multiple resident bedrooms. The 11 rooms consisted of two beds in each bedroom. This deficient practice had the potential to limit space to provide nursing care, and limit privacy for residents.