Astoria Healthcare Center: Medication Safety Failures - CA
The May 9 federal inspection at Astoria Healthcare Center found Licensed Vocational Nurse 2 had abandoned standard medication protocols for Resident 96, who takes bupropion for depression, buspirone for anxiety, carvedilol for high blood pressure, lisdexamfetamine for binge eating disorder, and vitamin D supplements.
When inspectors arrived at 10:50 a.m. on May 6, they found Resident 96 sitting up in bed with a clear plastic medicine cup containing two capsules and three tablets on the bedside rolling table. The resident told inspectors the medication belonged to her and that the nurse "left the medication on the table because the resident does not like to take all the medication at the same time."
The resident had forgotten to take the medications the nurse left behind.
Fourteen minutes later, LVN 2 returned to the room and told inspectors she "left the medication for Resident 96 to self-administer" because "Resident 96 was alert, and it was ok for Resident 96 to self-administer medication." The resident swallowed all five medications while the inspector watched.
After leaving the room, LVN 2 explained she "often leaves medication in Resident 96's room to self-administer one at a time" because the resident is alert.
But facility records show Resident 96 was never assessed for safe self-administration of medications. A March 24 assessment explicitly stated the resident "did not want to self-administer medication and the resident was not a candidate for safe self-administration of medication."
The nurse admitted her error during a later interview. LVN 2 told inspectors she "did not do an assessment when Resident 96 requested to self-administered medication or notify anyone of Resident 96's preference to self-administer medications, but LVN 2 should have."
She acknowledged leaving the five medications "unattended at Resident 96's bedside for the resident to self-administer but the resident was not assessed and did not have a physician's order for medication self-administration."
The facility's medication administration policy requires nurses to watch residents take medications to ensure safe administration, then document the date and time in the medication record. For self-administration, residents must undergo assessment to determine their ability to safely manage medications, followed by a physician's order specifying which medications they may self-administer.
Registered Nurse 1 told inspectors that when residents request to self-administer medications, "there should have been a new self-administration assessment completed because the resident was now requesting self-administration of medication."
Director of Nursing confirmed the policy violation had potential consequences beyond medication errors. When LVN 2 failed to follow up on the resident's request for self-administration, "there was a potential that the facility would go against the resident's rights and may result in psychosocial issues in Resident 96."
The medication incident was part of broader safety violations found throughout the 245-bed facility during the three-day inspection.
Inspectors discovered Resident 107's call light unplugged from the wall while the stroke patient with severe cognitive impairment lay in bed. The resident, who has hemiplegia affecting his right dominant side and requires substantial assistance with all daily activities, was at high risk for falls according to facility assessments.
Certified Nursing Assistant 5 found the disconnected call light and told inspectors "all residents' call lights should be plugged to the wall at all times to ensure the call light was functioning properly so the residents would be able to call for assistance when needed."
The CNA acknowledged that leaving Resident 107 without a functioning call light "placed Resident 107 at risk for a delay in meeting the resident's needs."
Environmental conditions throughout the facility reflected poor maintenance oversight. In Resident 17's room, inspectors found broken vertical blind slats scattered on the floor beside the bed, with pieces of cardboard taped to the sliding glass door to block security lights that shone through gaps in the damaged blinds.
The resident told inspectors he "wasn't happy at all about the situation because it has been like this for months." Staff had grown "tired of waiting for maintenance to fix the blinds" and resorted to the cardboard solution.
Certified Nursing Assistant 11 admitted requesting maintenance repairs in the past, but "recently had not requested maintenance to remove and fix the residents' blinds because CNA 11 was busy." The aide acknowledged "the blind slats should not be on the ground next to the resident's bed because it was not a homelike environment."
Physical restraint violations affected five residents who were subjected to restrictive devices without proper physician orders, informed consent, or safety assessments. Inspectors found residents with beds pushed against walls, three-sided bed rails with furniture blocking the open side, and bolstered mattresses that prevented normal movement.
Resident 28 had been sleeping on a bolstered mattress with raised edges since being discharged from hospice care on June 10, 2024. When hospice services ended, facility staff continued using the restrictive mattress without obtaining new physician orders or completing required restraint assessments.
Quality Assurance Coordinator told inspectors the original physician's order for the bolstered mattress "was not carried over to the current medical record but the facility continued to implement the use of the bolstered mattress."
The most serious medication violation involved Resident 154, who had been receiving Seroquel for "psychosis manifested by yelling for no reason" despite having no diagnosis of schizophrenia, depression, or bipolar disorder. A pharmacy recommendation dated April 3 explicitly stated that "the only acceptable diagnosis for Seroquel in the elderly is schizophrenia, depression or bipolar disorder" and recommended discontinuing the medication.
More than a month later, the facility had not followed up on the pharmacist's recommendation. Resident 154 continued receiving the unnecessary antipsychotic medication nightly.
The facility's own assessment from March 22 indicated Resident 154 "had no serious mental illness." The resident's medical records showed no hallucinations, delusions, or behavioral symptoms that would justify antipsychotic treatment.
Social Services Director confirmed that despite physician notes on April 13 calling for psychiatrist consultation, Resident 154 "was not seen by the Psychiatrist on 4/21/2025" and had not been added to the list of residents requiring psychiatric evaluation.
Director of Nursing acknowledged the medication represented "unnecessary chemical restraint" that placed the resident at risk for tardive dyskinesia, falls, and other serious side effects including "nausea, vomiting, dizziness and hypotension."
Advanced directive violations left three residents without proper documentation of their end-of-life wishes. Resident 72 had requested assistance formulating an advance directive on January 28, but after more than three months, the facility had not followed up with the ombudsman who was supposed to provide help.
Social Services Designee 1 found sticky notes dated March 5 and March 9 on a fax transmission report indicating the resident's continued interest in completing advance directives, but admitted "the facility did not follow up with the Ombudsman regarding the formulation of AD and just wait for the Ombudsman's availability."
The violations at Astoria Healthcare Center reflect systemic breakdowns in basic safety protocols, from medication management to environmental maintenance, affecting vulnerable residents who depend on staff for their most fundamental needs.
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.
When inspectors arrived at 10:50 a.m.
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.