SYLMAR, CA - Federal inspectors documented multiple infection control failures and safety lapses at Astoria Nursing and Rehab Center during a May 2025 inspection, revealing systemic issues in protecting vulnerable residents from potential harm.
Infection Control Failures Put Residents at Risk
The inspection uncovered significant breakdowns in the facility's infection prevention protocols, particularly concerning Enhanced Barrier Precautions (EBP) - a critical intervention designed to prevent transmission of dangerous multidrug-resistant organisms among residents.
Inspectors found that staff failed to implement proper EBP protocols for a resident with a documented history of vancomycin-resistant enterococcus (VRE), a particularly concerning type of antibiotic-resistant bacteria. Despite physician orders requiring enhanced precautions, the facility did not post required signage or provide isolation carts with personal protective equipment outside the resident's room.
During observations on May 7, 2025, a Licensed Vocational Nurse entered the resident's room wearing only gloves and a mask while administering oral medication - without the required protective gown. The nurse stated the resident was on "regular standard precautions," unaware of the enhanced requirements.
This represents a fundamental failure in infection control communication and implementation. VRE colonization persists even after active infection treatment ends, requiring ongoing preventive measures. The bacteria can survive on surfaces and healthcare workers' clothing, creating pathways for transmission to other medically fragile residents.
The facility's Infection Preventionist acknowledged the oversight, stating: "Resident 26 had a history of an MDRO. Residents with a history of MDRO should be on EBP, and Resident 26 had a history of an MDRO. The IP did not implement EBP for Resident 26 but should have."
When EBP protocols are not followed, antibiotic-resistant organisms can spread through direct contact or via contaminated surfaces and staff clothing. In congregate care settings housing immunocompromised individuals, such lapses create substantial risk for facility-wide outbreaks that may be difficult or impossible to treat with standard antibiotics.
Improper Equipment Disinfection Between Residents
The inspection revealed additional infection control concerns regarding the cleaning and disinfection of shared equipment. Inspectors observed a Restorative Nursing Aide using a cloth gait belt with a resident on Enhanced Barrier Precautions, then attempting to disinfect the porous fabric material with sanitizing wipes before using it with another resident.
This practice violates basic infection control principles. Disinfecting wipes are formulated for non-porous surfaces and cannot adequately penetrate and sanitize fabric materials. Cloth gait belts can harbor bacteria, viruses, and other pathogens within their fibers, creating reservoirs that persist despite surface wiping.
The facility's Infection Preventionist confirmed that "cloth gait belts were considered porous surfaces and the disinfecting wipes could only be used for non-porous surfaces." The IP further explained that improper disinfection of shared equipment between residents poses particular risks when residents have multidrug-resistant organisms, as "the bacteria could stay on the gait belt and the bacteria could be transmitted to another resident."
Proper infection control protocols require either using vinyl (non-porous) gait belts that can be adequately disinfected between uses, or laundering fabric belts according to healthcare textile standards between each resident use. The failure to follow these protocols creates unnecessary infection transmission pathways.
Protective Equipment Worn Incorrectly
Even when staff attempted to use personal protective equipment, inspectors documented improper technique that compromised its effectiveness. During medication administration to a resident requiring Enhanced Barrier Precautions, a nurse wore a protective gown but failed to secure it at the back of the neck and waist, leaving it open and defeating its protective purpose.
Proper gown technique requires the garment to be fully secured, with the opening at the back completely closed by ties or fasteners at both the neck and waist. This ensures complete coverage of the healthcare worker's clothing and prevents contamination. An unsecured gown allows pathogens to reach the worker's clothing underneath, which then becomes a vector for transmission to other residents.
During a bed bath observation, another nursing assistant failed to wear any protective gown while providing high-contact care to a resident on Enhanced Barrier Precautions. According to facility policy, gowns must be worn during activities including bathing, dressing, transferring, hygiene assistance, linen changes, toileting assistance, and wound care.
The Director of Nursing acknowledged these failures compromised infection prevention: "PPE like gowns are used to prevent spread of infection." High-contact care activities create the greatest risk for pathogen transmission, making proper protective equipment use during these tasks particularly critical.
Medication Bottles and Sanitation Concerns
Inspectors identified sanitation issues affecting medication administration. During medication cart reviews, they found bottles of Prostat liquid nutritional supplement with dried residue and "yellow drippings" on the exterior across three different medication carts. The bottles were described as "sticky to touch" with visible staining.
Nursing staff acknowledged that medication bottles should be wiped clean before and after each use to prevent contamination and maintain sanitation. Allowing residue to accumulate on medication containers creates potential for bacterial growth and cross-contamination. When nurses handle contaminated bottle exteriors, pathogens can transfer to their gloves and subsequently to other surfaces, medications, or residents.
This issue reflects inadequate attention to basic hygiene practices during medication administration. Standard protocols require maintaining clean medication preparation areas and equipment to minimize infection risks during this high-frequency care activity.
Respiratory Equipment Maintenance Issues
The inspection revealed concerning practices regarding respiratory equipment care for a resident using a BiPAP machine - a device providing breathing support during sleep. Inspectors found the BiPAP mask hanging unsecured on the resident's wheelchair brake handle, exposed to environmental contamination.
Staff reported inconsistent practices for cleaning the equipment. One nurse stated she used alcohol sanitizer wipes, while another reported washing the mask with antibacterial soap and water nightly. However, documentation showed cleaning was not consistently performed or recorded.
Respiratory equipment requires meticulous care because it directly contacts airways and mucous membranes. Contaminated equipment can introduce bacteria directly into the lungs, causing pneumonia and other respiratory infections. This poses particular risks for residents with underlying respiratory conditions who depend on such devices.
The facility's Director of Nursing acknowledged that staff should follow manufacturer instructions for cleaning respiratory equipment and document these activities. The nebulizer equipment was also found stored improperly in an unlabeled plastic bag, making it impossible to verify cleanliness or track when components should be replaced.
Food Texture Consistency Failures
Beyond infection control, inspectors identified issues with modified diet preparation that could affect resident safety. For residents requiring pureed diets due to swallowing difficulties, food must meet specific consistency standards to prevent choking and aspiration.
The facility follows International Dysphagia Diet Initiative (IDDSI) Level 4 standards, which require pureed foods to pass a "spoon tilt test" - the food should fall off a tilted spoon in a single cohesive portion without sticking. During meal observation, pureed mixed vegetables failed this test, with food remaining stuck to the spoon.
The food service aide stated she only checked consistency by mixing, not by performing the required tilt test. When foods are too thick, they become difficult to swallow and increase aspiration risk - when food or liquid enters the airways instead of the esophagus, potentially causing pneumonia.
The Dietary Director confirmed: "When puree foods are too thick the residents are at risk for aspiration and intolerance." Facility recipes specify that texture-modified foods must pass established testing methods at the start of service and every 15 minutes throughout the meal period.
Additional Issues Identified
Inspectors documented several other concerns affecting resident care and safety:
Therapy Services: One resident did not receive prescribed occupational therapy five times weekly as ordered, receiving treatments only once weekly during two separate weeks. Incomplete therapy provision can delay functional recovery and goal achievement.
Medical Records: Therapy documentation was completed late, with progress reports and discharge summaries signed up to two weeks after the documented dates. Delayed documentation impairs care coordination and communication among healthcare team members.
Antibiotic Tracking: The facility's antibiotic monitoring log was incomplete, missing documentation when one resident's antibiotic was changed based on laboratory sensitivity results. Comprehensive antibiotic tracking helps ensure appropriate prescribing and monitors for resistance patterns.
Physical Environment: The therapy gym contained equipment stored on treatment surfaces, reducing available space for resident therapy sessions. A freezer light bulb was not working, creating visibility issues for food safety monitoring.
The inspection findings reflect systemic gaps in staff training, supervision, and quality oversight across multiple departments. Federal standards require nursing facilities to implement infection prevention and control programs that protect residents from healthcare-associated infections - among the most common complications of institutional care and a leading cause of morbidity and mortality in this population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Nursing and Rehab Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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