SYLMAR, CA - Federal inspectors documented multiple care planning failures at Astoria Nursing and Rehab Center that compromised infection control protocols and pressure injury prevention for high-risk residents.
Infection Control Protocols Breakdown
The most serious violations involved failures to maintain proper infection control measures for residents with vancomycin-resistant enterococcus (VRE), a dangerous antibiotic-resistant bacteria. VRE infections pose significant health risks, particularly for nursing home residents with compromised immune systems or multiple medical conditions.
One resident with a documented history of VRE infection was placed under contact isolation precautions from March 15-18, 2025. However, when the contact isolation order was discontinued, facility staff failed to update the resident's care plan to reflect the new enhanced barrier precaution (EBP) requirements. This oversight created confusion among nursing staff about which protective protocols to follow.
The facility's Infection Preventionist acknowledged that care plans should have been updated when the isolation status changed but confirmed this critical step was not completed. Enhanced barrier precautions require targeted use of gowns and gloves during high-contact care activities to prevent transmission of drug-resistant organisms.
VRE bacteria can survive on surfaces for extended periods and spread through contact with contaminated hands, equipment, or surfaces. When proper precautionary protocols are not followed consistently, these infections can spread rapidly through healthcare facilities, potentially causing serious complications including bloodstream infections, wound infections, and urinary tract infections that are difficult to treat with standard antibiotics.
Care Plan Communication Failures
The Director of Nursing confirmed that care plans serve as essential communication tools to ensure all staff understand how to provide appropriate care with proper interventions. When plans are not updated to reflect current physician orders, staff may follow outdated protocols that no longer match the resident's medical needs.
"When Resident 26's CP was not revised the CP indicating to implement contact isolation could create confusion among staff regarding the proper precautionary measures to prevent the spread of MDROs," the Director stated during the inspection.
This breakdown in communication protocols violated the facility's own policy requiring care plans to be revised as resident conditions and treatment orders change. Proper care plan maintenance ensures that all nursing staff, across different shifts, follow consistent and appropriate infection control measures.
Pressure Injury Prevention Equipment Misuse
Inspectors identified serious deficiencies in the operation of specialized low air loss mattresses (LALM) designed to prevent pressure injuries in high-risk residents. These therapeutic mattresses must be calibrated to each resident's specific weight to function properly and provide adequate pressure relief.
Two residents requiring pressure injury prevention were found to have incorrectly set mattresses. One resident weighing 158 pounds had their mattress set for 130 pounds, while another resident weighing 152 pounds had their mattress configured for 270 pounds - nearly double their actual weight.
Licensed Vocational Nurse staff confirmed during the inspection that "the LALM should be set according to resident's weight to prevent Resident 153 from developing pressure injuries." However, these critical adjustments were not being made consistently.
Medical Consequences of Equipment Failures
Improperly calibrated pressure relief mattresses can lead to serious complications for vulnerable residents. When set below a resident's actual weight, the mattress may not provide adequate pressure distribution, increasing the risk of pressure ulcers developing. Conversely, settings that are too high can create excessive firmness that fails to relieve pressure points effectively.
Pressure injuries represent a significant health concern for nursing home residents, particularly those with diabetes, circulation problems, or limited mobility. These wounds can progress rapidly from superficial skin damage to deep tissue injury affecting muscle and bone. Advanced pressure injuries may require surgical intervention and can lead to serious infections, prolonged hospitalization, or life-threatening complications.
The residents affected by the mattress setting errors were already identified as high-risk for pressure injury development based on standardized assessment tools. Both had physician orders specifically requiring continuous use of pressure-reducing devices, making the equipment failures particularly concerning.
Nursing Standards and Care Plan Requirements
Federal regulations require nursing facilities to develop comprehensive, person-centered care plans that include measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs. These plans must be updated when there are significant changes in the resident's condition or when new interventions are implemented.
The facility's own policy mandated care plan reviews and updates in multiple circumstances, including when desired outcomes are not met, when residents are readmitted from hospital stays, and at least quarterly in conjunction with required assessments. The documented failures represented violations of both federal standards and internal protocols.
Licensed nursing staff acknowledged that care plans should reflect current interventions being implemented for residents to ensure standardized care and prevent miscommunication among healthcare providers. When plans are not updated to include new medical equipment or changed isolation requirements, the continuity of care becomes compromised.
Industry Standards for Prevention
Professional medical standards emphasize the critical importance of accurate equipment calibration for pressure injury prevention devices. Low air loss mattresses work by distributing body weight evenly and maintaining optimal skin temperature and moisture levels. When weight settings are incorrect, these therapeutic benefits are significantly reduced.
Similarly, infection control protocols in healthcare settings follow strict evidence-based guidelines designed to prevent the transmission of dangerous pathogens. Enhanced barrier precautions for multidrug-resistant organisms represent a scaled approach that provides targeted protection while allowing for more normal resident activities compared to full isolation measures.
The documented violations at Astoria Nursing and Rehab Center highlight the importance of consistent staff training, regular equipment monitoring, and systematic care plan maintenance in protecting resident health and safety. Effective infection control and pressure injury prevention require coordinated efforts across all levels of nursing staff and administrative oversight.
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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