Bellflower Post Acute: Infection Control Failure CA
BELLFLOWER, CA - A February 2025 health inspection at Bellflower Post Acute nursing facility revealed significant infection control lapses, incomplete vaccination records, and inadequate room sizes that placed residents at risk for infections and compromised their care environment.
Critical Infection Control Failures Documented
State health inspectors documented multiple instances where staff failed to follow basic infection prevention protocols during their February 18-21 inspection. The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents.
In one observed incident, inspectors found a resident's urinary catheter tubing dragging on the floor while the resident sat in his wheelchair in the activity room. The catheter bag was attached to the back of the wheelchair, but the tubing extended from the resident's pant leg and made contact with the floor surface. When confronted, Licensed Vocational Nurse 4 acknowledged that "it is nurses' responsibility to make sure the foley catheter is off the floor before taking the resident from his room."
Catheters that contact floor surfaces become contaminated with bacteria and pathogens commonly found in healthcare environments. When contaminated tubing remains connected to a resident's bladder, these microorganisms can travel up the catheter and cause urinary tract infections. For elderly nursing home residents, urinary tract infections can quickly progress to kidney infections or bloodstream infections, potentially becoming life-threatening. The facility's own care plan for this resident specifically stated to "place all tubing without touching the floor."
Personal Protective Equipment Violations Put Residents at Risk
Inspectors observed a nurse failing to follow proper safety protocols when caring for a resident requiring Enhanced Barrier Precautions. The resident, who had a gastrostomy tube for feeding and suffered from Huntington's Disease, required staff to wear protective gowns during care activities. However, Licensed Vocational Nurse 3 entered the resident's room without performing hand hygiene and only wore gloves while checking the resident's feeding tube.
The nurse admitted to inspectors that she "should have been wearing a gown when observing Resident 15's g-tube" and acknowledged that "not wearing PPE exposes staff to more bacteria." The lack of readily accessible protective equipment compounded the problem. Gowns were stored at nursing stations rather than outside rooms of residents requiring enhanced precautions, creating barriers to proper compliance.
Gastrostomy tubes create direct openings into the body that bypass natural immune defenses. When healthcare workers fail to use appropriate protective equipment, they can transfer bacteria from other residents or contaminated surfaces directly to these vulnerable sites. This increases the risk of surgical site infections, which in gastrostomy patients can lead to peritonitis, sepsis, and other serious complications requiring hospitalization.
Vaccination Documentation Failures Leave Residents Unprotected
The facility failed to maintain proper vaccination records for multiple residents, including one resident who had no documentation of receiving influenza or pneumococcal vaccines despite being admitted months earlier. The resident, who had cerebral palsy, asthma, and required tube feeding, represented a particularly high-risk individual for respiratory infections.
The Infection Prevention Nurse admitted that her vaccination tracking spreadsheet "was not up to date and has residents that have already been discharged." When asked about the undocumented resident, she confirmed the resident was not listed on her tracking system. Facility policy required evaluating all residents for vaccination status upon admission and offering appropriate vaccines within seven days.
Pneumococcal disease causes approximately 150,000 hospitalizations annually among elderly adults, with mortality rates reaching 20-40% in nursing home populations. For residents with underlying conditions like asthma and swallowing difficulties, pneumococcal pneumonia poses even greater risks. The lack of vaccination documentation meant the facility could not verify whether this vulnerable resident had protection against these preventable diseases.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BELLFLOWER POST ACUTE in BELLFLOWER, CA was cited for violations during a health inspection on February 21, 2025.
The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.