BELLFLOWER, CA - Federal inspectors documented multiple safety violations at Cerritos Vista Healthcare Center during a March 2025 inspection, including the administration of expired respiratory medication to a resident with chronic obstructive pulmonary disease (COPD) for three consecutive days.
Expired Medication Administration Threatens Respiratory Care
The most serious violation involved a resident with COPD and asthma who received expired fluticasone and salmeterol inhaler medication from March 17-19, 2025. The combination medication, prescribed to manage chronic respiratory conditions, had expired on March 17 but remained in the facility's medication cart.
Three different licensed nurses administered the expired medication without checking the expiration date. According to the inspection report, the nurses involved were LVN 1, LVN 4, and LVN 5, who administered doses on different shifts during the three-day period.
Medical Significance of Expired Respiratory Medication
Fluticasone and salmeterol is a combination medication containing a corticosteroid and long-acting bronchodilator used to prevent breathing difficulties in COPD and asthma patients. When this medication expires, its potency and effectiveness diminish significantly.
Expired respiratory medications can lead to inadequate symptom control, potentially causing increased breathing difficulties, more frequent asthma attacks, or COPD exacerbations. Patients may require emergency medical intervention if their chronic respiratory condition becomes poorly controlled due to ineffective medication.
The manufacturer's labeling clearly stated the inhaler should be discarded one month after opening or when the counter reads zero. The facility's registered nurse supervisor confirmed that administering expired medication "may reduce the efficacy, potency, and quality of the medication and the resident may not respond well to the treatment."
Medication Storage and Oversight Failures
The inspection revealed systematic problems with medication management beyond the expired inhaler. Inspectors found unauthorized antacid medication (TUMS) at a resident's bedside despite the facility's assessment that the resident was unable to safely self-administer medications.
The resident told inspectors that staff had instructed her to hide the TUMS because "state surveyors were in the facility." When questioned, a licensed vocational nurse confirmed the medication should not have been accessible to the resident without a physician's order.
Risks of Unsupervised Medication Access
Self-administration of over-the-counter medications by residents who lack capacity creates multiple safety risks. These include potential drug interactions with prescribed medications, masking of symptoms that require medical attention, and possible overdose situations.
The facility's own assessment determined this resident required assistance to correctly identify medications, understand their purposes, and determine appropriate dosing. Such cognitive limitations make unsupervised access to any medication potentially dangerous.
Food Safety and Infection Control Deficiencies
Inspectors documented extensive food safety violations that placed all 130 residents at risk for foodborne illness. Multiple food items in storage areas lacked proper dating, labeling, and sealing.
In the dry storage area, opened seasonings, grains, and bread products were found without use-by dates or proper sealing. The walk-in refrigerator contained prepared foods, condiments, and dairy products that were similarly mislabeled or improperly stored.
Temperature Control Violations
During lunch service, kitchen staff discovered ground beef patties in the steam tray had dropped to 138°F, well below the facility's required 155°F minimum for ground meat safety. This temperature failure occurred despite staff checking temperatures less than 10 minutes earlier.
Inadequate food temperatures create ideal conditions for bacterial growth, particularly dangerous pathogens like E. coli and Salmonella that can cause severe illness in elderly residents with compromised immune systems.
Infection Prevention Breakdowns
The facility failed to maintain proper infection control practices in multiple areas. Treatment staff were observed checking resident meal trays without performing hand hygiene between tasks, touching contaminated surfaces, and adjusting personal protective equipment.
Equipment Disinfection Issues
Bed rails padded with foam and paper tape for a seizure patient were not being properly disinfected. Staff were using bleach wipes designed for hard, non-porous surfaces on the porous foam padding.
The facility's infection preventionist explained that improper disinfection of porous materials can harbor bacteria and create cross-contamination risks. The foam padding required different cleaning protocols than hard surfaces to ensure effective sanitization.
Medication Administration Hand Hygiene
Licensed nursing staff failed to perform required hand hygiene before administering medications to residents. One nurse was observed preparing multiple oral medications and entering a resident's room without washing or sanitizing hands, then assisting the resident with drinking water using unclean hands.
Dental Care Coordination Problems
A resident who had been without dentures for several months was not receiving adequate follow-up care despite documented eating difficulties and social embarrassment. The resident reported requesting replacement dentures from social services but receiving no updates on the status.
The facility's social service director acknowledged not following up after a dental visit where the resident reportedly declined treatment. The director admitted she should have investigated the reason for refusal, as proper dental care is essential for nutrition and quality of life.
Regulatory Standards and Facility Response
Federal nursing home regulations require facilities to ensure residents receive medications as prescribed by their physicians, maintain safe food storage and preparation practices, and implement comprehensive infection prevention programs.
The facility's own policies and procedures addressed many of the violations found during inspection, including requirements for checking medication expiration dates, proper food labeling and storage, and hand hygiene protocols. The violations indicate failures in staff training, supervision, and quality assurance processes.
Industry Best Practices
Effective medication management requires multiple safeguards including regular expiration date checks, proper storage protocols, and staff training on the five rights of medication administration. Food safety programs should include daily temperature monitoring, proper labeling systems, and regular staff education on safe food handling practices.
Infection prevention requires consistent adherence to hand hygiene protocols, appropriate use of personal protective equipment, and proper disinfection procedures for all surfaces and equipment that come into contact with residents.
The March 2025 inspection classified these violations as having "minimal harm or potential for actual harm," indicating the problems were identified before causing serious resident injury. However, the systemic nature of the violations suggests the need for comprehensive staff retraining and enhanced quality oversight procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cerritos Vista Healthcare Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
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