Bellflower Post Acute

In the surveyor’s words

From the most serious findings on record at Bellflower Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF688Jul 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided active range of motion ([AROM] movement at a given joint when the person moves voluntarily) to his left and right upper extremities (upper arm, forearm, wrist, hand and fingers and thumb) from 3/28/2022 through 7/11/2023. ` This deficient practice resulted in Resident 1 developing a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) to his left hand, pain upon movement of his left hand, the inability to fully straighten the 1st, 3rd, 4th, and 5th fingers of his left hand or use his left hand as needed to complete his activities of daily living ([ADLs] task such as… […]

• Actual harm, isolatedF580Nov 17, 2021

  Based on interview and record review, the facility failed to ensure the licensed nurses notified a physician of the resident's vomiting episodes per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in Resident 1's continuous vomiting on [DATE], becoming unresponsive, and subsequently dying in the facility on [DATE] at 7:17 AM. Resident 1 died from complications of [CONDITION(S)] (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration (when something enters the airways by accident) of contaminated gastric contents.] Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility initially admitted Resident 1 on [DATE] and readmitted on [DATE], with… […]

• Actual harm, isolatedF684Nov 17, 2021

  Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with quality of care consistent with maintaining Resident 1's highest practicable physical well-being, by failing to: a. Thoroughly assess and evaluate Resident 1 after having episodes of vomiting (forcefully expelling the stomach's contents out of the mouth). b. Notify the physician when Resident 1 had episodes of vomiting in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Stop Resident's 1 oral intake until the physician was notified and determined it was safe to restart oral intake after Resident 1's episodes of vomiting. d. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based 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.Findings:During a concurrent observation and interview on April 15, 2026, at 1:55 PM with the Maintenance Director (MS) in the facility's kitchen, the facility's ice machine was observed for inspection. […]

• No harm, potential for more than minimal, widespreadF867Apr 16, 2026

  Based 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.Findings:During a concurrent interview and record review on 4/16/2026 at 2:38 p.m. with the Administrator (ADM), the facility's QAPI binder was reviewed. The ADM stated the facility has identified falls, pressure injuries, and legionella water management as active QAPI topics. […]