SYLMAR, CA - Federal inspectors identified serious deficiencies in patient care and safety protocols at Astoria Nursing and Rehab Center during a May 9, 2025 inspection, citing violations affecting medication management, respiratory care, accident prevention, and basic patient safety measures.
Critical Medication Administration Failures
The inspection revealed widespread medication management problems affecting eight residents. Licensed Vocational Nurse (LVN) staff committed fundamental errors that could have resulted in serious health consequences.
In one case, an LVN administered 100 milligrams of docusate sodium to a resident whose physician had ordered 250 milligrams - providing less than half the prescribed dose for treating constipation. This underdosing rendered the medication ineffective and could have prolonged the resident's discomfort.
More concerning was the near-administration of expired medication. An LVN prepared to give docusate sodium with an April 2025 expiration date to a resident on May 6, 2025, only stopping when inspectors intervened. The nurse admitted to not checking the expiration date before preparing the medication - a basic safety requirement that could have exposed the resident to ineffective treatment and potential adverse reactions.
The facility's medication timing protocols also failed multiple residents. Staff administered morning medications scheduled for 9 a.m. as late as 10:38 a.m. to one resident and 9:18 a.m. to another whose medication was due at 7 a.m. These delays exceeded the facility's one-hour window for medication administration. Such timing errors can be particularly dangerous for medications like blood pressure drugs and diabetes medications, where precise timing maintains therapeutic levels and prevents dangerous fluctuations.
Proper medication administration requires adherence to the "five rights": right patient, right medication, right dose, right route, and right time. These fundamental failures demonstrate inadequate staff training and oversight in pharmaceutical services.
Respiratory Equipment Safety Compromised
The inspection uncovered serious deficiencies in respiratory care affecting four residents requiring life-sustaining breathing support. Staff failed to follow basic infection control and equipment maintenance protocols that could have led to respiratory infections or treatment failures.
One resident using a BiPAP machine - essential for treating sleep apnea and breathing difficulties - had his mask stored improperly on a wheelchair brake handle instead of in a clean, designated area. The nebulizer equipment lacked proper labeling with the resident's name and change date, violating infection control standards. Most critically, staff were not cleaning the BiPAP equipment according to manufacturer specifications, which require weekly washing with mild detergent and daily humidifier maintenance.
For three other residents requiring oxygen therapy and nebulizer treatments, respiratory tubing and masks were not dated to track when they were last changed. Industry standards require changing respiratory equipment every 5-10 days to prevent bacterial contamination. Without proper dating, equipment could remain in use far beyond safe timeframes, creating significant infection risks.
These respiratory care failures are particularly dangerous for nursing home residents, who often have compromised immune systems and underlying lung conditions. Contaminated respiratory equipment can introduce harmful bacteria directly into the lungs, potentially causing pneumonia or other serious respiratory infections.
Dangerous Safety Hazards Throughout Facility
Inspectors found multiple accident hazards that placed residents at unnecessary risk of injury. The most concerning involved medications and hazardous substances left accessible in resident rooms without proper supervision.
Staff left prescription medications - including blood pressure, anxiety, and depression medications - unattended at residents' bedsides for self-administration, despite facility policies requiring supervised medication administration. One nurse stated leaving medications was acceptable because the resident was "alert," even though the resident had not been assessed for safe self-administration and lacked physician authorization.
In the same room, inspectors found an aerosol can of ant, roach, and spider killer stored near food items on the resident's dresser. This pesticide remained accessible for over 24 hours after multiple staff members entered the room, violating basic safety protocols. Chemical pesticides pose serious respiratory and poisoning risks, especially when stored near consumable items.
The facility's fall prevention measures also showed dangerous deficiencies. Heavy furniture and medical equipment were placed on top of protective floor mats designed to cushion residents during falls. One mat had a 16-inch tear in its surface. These violations compromised the mats' protective function and created additional hazards during fall incidents.
One heating pad was found in use without a physician's order, creating burn and electrocution risks for a resident with severely impaired cognitive function who could not safely monitor the device's use.
Feeding Tube Care Standards Violated
Two residents requiring feeding tubes for nutrition experienced care failures that could have resulted in infections or nutritional complications. Staff failed to properly label feeding formula and water flush bags with essential information including hang time, administration rate, and frequency.
Proper labeling is critical for feeding tube safety because it ensures accurate nutrition delivery and helps staff identify when formula has exceeded safe hanging times. Unlabeled or improperly labeled feeding supplies can lead to over- or under-hydration, nutritional deficits, and increased infection risk.
Staff also failed to properly cap and store feeding tube valves when disconnected, potentially exposing residents to gastrointestinal infections through contaminated equipment.
Restorative Care Programs Incomplete
The facility's restorative nursing program, designed to maintain residents' physical function and prevent decline, showed significant gaps. During one observed session, a restorative nursing aide failed to perform ordered range-of-motion exercises on a resident's left upper extremity, completing only half the prescribed therapy.
Range-of-motion exercises are essential for preventing joint stiffness, muscle atrophy, and functional decline in nursing home residents. Missing these treatments can accelerate physical deterioration and reduce residents' quality of life and independence.
Inadequate Staff Training and Oversight
The violations reveal systemic problems with staff competency and supervision. One certified nursing assistant had not received required annual skills assessment since January 2024, violating federal requirements for ongoing competency verification.
Multiple staff members demonstrated lack of knowledge about basic safety protocols, infection control standards, and medication administration requirements. The Director of Nursing acknowledged that staff failures "predisposed residents' skin to break down" and could "cause bacterial accumulation and potentially cause infection."
Industry Standards and Best Practices
Federal nursing home regulations require facilities to provide pharmaceutical services that ensure accurate medication administration, maintain infection control standards for all medical equipment, and eliminate environmental hazards. The Centers for Medicare & Medicaid Services mandates that residents receive necessary care to maintain their highest possible physical and mental functioning.
Best practices in nursing home care include systematic medication reconciliation, regular equipment maintenance schedules, comprehensive staff training programs, and robust quality assurance monitoring. The multiple violations at Astoria Nursing and Rehab Center suggest inadequate implementation of these fundamental safety systems.
Additional Issues Identified
Beyond the major violations, inspectors documented problems with medication disposal logs missing required signatures and dates for 19 discarded medications, improperly set low air loss mattresses that could contribute to pressure ulcer development, and incomplete documentation of medical treatments.
The facility's 6.45% medication error rate exceeded the federal maximum of 5%, demonstrating systemic problems with pharmaceutical care quality and safety protocols.
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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