Astoria Healthcare Center: Medication Safety Failures - CA
Federal inspectors found that staff at Astoria Healthcare Center failed to rotate injection sites for Resident 12 from March through May 2025, despite facility policies requiring the practice. The resident received insulin injections four times daily under a sliding scale protocol.
Medication records showed a disturbing pattern. On March 14 and 15, nurses gave both the 11:30 a.m. and 4:30 p.m. injections in the exact same abdominal quadrant each day. From April 11 through April 26, staff administered multiple doses exclusively to the resident's right lower abdomen. The pattern continued into May.
"There were multiple instances that the site of insulin administration was not rotated," Registered Nurse 3 told inspectors during a May 9 review of the resident's records. The nurse acknowledged this constituted a medication error.
The consequences extend beyond bureaucratic violations. Repeated injections in the same location cause lipodystrophy — abnormal fat distribution under the skin that creates lumps and indentations. When insulin is injected into these damaged areas, absorption becomes unpredictable.
"Injecting insulin on the sites of lipodystrophy could affect the absorption of the insulin that can cause hypo/hyperglycemia to residents," the registered nurse explained to inspectors.
Director of Nursing confirmed the seriousness of the violations. "The resident can experience hypo/hyperglycemic episodes due to poor absorption of the insulin on the sites of lipodystrophy," she told inspectors.
Resident 12 had been living at the facility since February 2020 with multiple health conditions including Type 2 diabetes, glaucoma, and left-side paralysis affecting primarily the upper extremity. Assessment records from January 2025 showed the resident had intact thinking abilities and could communicate effectively with staff.
The facility's own policies explicitly required site rotation. Their insulin administration guidelines, last reviewed in January 2025, stated that "injection sites should be rotated, preferably within the same general area." The policy recommended using subcutaneous tissue in the upper arms, thighs, and abdomen while avoiding the area around the navel.
Manufacturer guidelines for Humalog, the specific insulin prescribed to Resident 12, carry the same warning: "rotate injection sites to reduce risk of lipodystrophy."
But policy knowledge didn't translate to practice. Inspectors found expired medications scattered throughout the facility's storage areas, suggesting broader problems with pharmaceutical oversight.
In Station A's medication room, two unlabeled vials of meropenem sat in the IV cart. These antibiotic vials should have been discarded after a resident's treatment ended, but remained unmarked and available for potential misuse.
Registered Nurse 5 discovered the problem during the inspection. The vials were leftover from Resident 19's treatment, which had concluded days earlier. "The two meropenem vials should have been discarded after the dose was completed," the nurse told inspectors.
Station B's medication cart contained expired psyllium and docusate sodium, both used to treat constipation. One Licensed Vocational Nurse was observed taking expired docusate sodium from a bottle without noticing the expiration date had passed.
"I did not notice that the docusate sodium was expired," LVN 2 admitted to inspectors. "The medication cart should not contain expired medication to prevent medication error."
The Director of Staff Development explained the potential consequences: "Expired medication could be less effective and could cause possible adverse reaction."
For one resident who needed the expired docusate sodium, this meant risking continued constipation if the medication had lost its effectiveness.
Beyond medication management, the facility struggled with basic coordination of medical services. Resident 128 waited 42 days for a CT scan that should have been completed within a week of the physician's order.
The orthopedic specialist ordered the scan on September 9, 2024, requesting the resident return in one week with results. Instead, administrative delays pushed the actual scan to October 21 — six weeks later.
The business office didn't request insurance authorization until October 9, a full month after receiving the original order. When authorization came back the next day showing none was needed, more delays followed before the scan finally occurred.
"Resident 128 should not have received the CT scan more than a month later from the order," the Director of Nursing told inspectors. "The delay in receiving the CT scan could cause potential harm to the resident and Resident 128 could have deteriorated."
The orthopedic physician noted the consequences when the resident finally returned: "45 days later with poor quality CT scan."
Resident 128 had been admitted with muscle wasting and a fractured upper arm bone. The delayed imaging meant delayed assessment of healing and potential complications from the fracture.
In the facility's kitchen, training gaps created additional safety risks. Cook 1 could not properly prepare pureed vegetables for residents with swallowing difficulties, creating foods too thick to pass safety tests designed to prevent choking.
The puree consistency failed the spoon-tilt test, which measures whether food holds together appropriately for residents who cannot safely swallow regular textures. Foods that are too thick or don't maintain proper consistency can cause aspiration — when food particles enter the airway instead of going to the stomach.
These violations occurred at a facility that has housed residents for years, with established policies covering each area of deficiency. The problems weren't about missing procedures but about staff failing to follow existing protocols consistently.
Resident 12 continues receiving insulin injections. Whether staff have corrected their injection site rotation practices remains unclear from the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Healthcare Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Astoria Healthcare Center in SYLMAR, CA was cited for violations during a health inspection on May 9, 2025.
The resident received insulin injections four times daily under a sliding scale protocol.
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.