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Health Inspection

Astoria Healthcare Center

May 9, 2025 · Sylmar, CA · 14040 Astoria Street
Citations 7
CMS Rating 1/5
Beds 218
Provider ID 056084
Healthcare Facility
Astoria Healthcare Center
Sylmar, CA  ·  View full profile →
Inspection Summary

Astoria Healthcare Center in SYLMAR, CA — inspection on May 9, 2025.

Found 7 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF584
Minimal harm or Some affected

During an observation and interview on 5/6/2025 at 7:55 a.m. with DA 1, during the kitchen tour, DA 1 stated inside the meat freezer that stores milk the light bulb was not working. DA 1 stated the light bulb should be working and she does not know when the light bulb went out. DA 1 stated no one had told her the light bulb was not working.

During an interview on 5/9/2025 at 1:48 p.m. with the Dietary Director (DD), the DD stated she has not been made aware that the light bulb was broken and not working.

The DD stated this requires a specialty order and would take time for it to be delivered to them.

The DD stated this should be in working order to ensure that the kitchen staff is able to see what is inside and keep the inside of the freezer clean.

During a review of the facility's policy and procedure titled, Maintenance of Equipment, reviewed and approved 1/16/2025, the P&P indicated it is the policy of the facility to have equipment that is in optimal working condition; all equipment should be clean inside and outside; food and nutrition supervisor shall be notified if equipment needs repairs; or needs to be replaced; maintenance should be notified if equipment is broken or not functioning as it should.

43988

2.

During a review of Resident 65's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 10/3/2015 and readmitted in the facility on 10/24/2022, with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral palsy (a group of permanent movement and posture disorders of the developing fetal or infant brain which limit activity), and major depressive disorder, and dysphagia (difficulty swallowing).

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

During a review of Resident 153's Face Sheet, the Face Sheet indicated the facility admitted the resident on 3/13/2024, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage that can occur due to diabetes), adult failure to thrive (due to declining physical and mental health, there is lost weight, depleted energy, and the diminished ability of an individual to care for oneself), and palliative care (specialized medical care for people with serious illnesses that focuses on improving their quality of life by managing symptoms and providing support, both physically and emotionally).

During a review of Resident 153's History and Physical (H&P), dated 4/11/2025, the H&P indicated the resident can make needs known but cannot make medical decisions.

During a review of Resident 153's Minimum Data Set (MDS, a resident assessment tool), dated 3/14/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (noticeable deficits that interfere with daily activities, including memory loss, language difficulties, skewed judgment, and reduced problem-solving abilities).

The MDS indicated the resident was dependent to requiring supervision on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).

The MDS indicated the resident was at risk for developing pressure ulcers/injuries and had pressure reducing device for bed.

During a review of Resident 153's Physician Order Sheet, dated 4/15/2025, the Physician Order Sheet indicated an order for low air loss mattress continuous.

During a review of Resident 153's Braden Scale for Predicting Pressure Sore Risk, dated 4/28/2025, the Braden Scale for Predicting Pressure Sore Risk indicated the resident was at high risk for developing pressure sore/injuries.

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

During a review of Resident 12's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/12/2020, with diagnoses including diseases of gallbladder (a small organ that stores bile), glaucoma (a

potential for actual harm leading to vision loss and potentially blindness), and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 12's History and Physical (H&P), dated 11/24/2024, the H&P indicated the resident was awake, alert, oriented, and responding appropriately; had left hemiplegia (paralysis that affects only one side of the body), more on the left upper extremity, and unable to test gait (a manner of walking or moving on foot).

During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 1/31/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).

The MDS indicated the resident was on a high-risk drug class hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood).

During a review of Resident 12's Physician Order Sheet, dated 12/10/2023, the Physician Order Sheet indicated an order of Humalog U-100 Insulin 100 units per milliliter (unit/mL, one unit of insulin is equal to 0. 01 mL) subcutaneous solution (sliding scale, the increasing administration of the pre meal insulin dose based on the blood sugar level before the meal), Vial (ml, a unit of volume) Subcutaneous four times daily.

During a review of Resident 12's Medications from 3/2025 to 5/2025, the Medications indicated insulin Humalog U-100 Insulin 100 unit/mL subcutaneous solution (sliding scale), Vial (ml) Subcutaneous four times daily was administered on:

3/4/2025 at 9 p.m. on the Abdomen- Right Upper Quadrant (RUQ)

3/5/2025 at 6:30 a.m. on the Abdomen-RUQ

3/7/2025 at 4:30 p.m. on the Abdomen

3/7/2025 at 9 p.m. on the Abdomen

3/8/2025 at 4:30 p.m. on the Abdomen- Left Upper Quadrant (LUQ)

3/8/2025 at 9 p.m. on the Abdomen-LUQ

3/14/2025 at 11:30 a.m. on the Abdomen-LUQ

3/14/2025 at 4:30 p.m. on the Abdomen-LUQ

3/15/2025 at 11:30 a.m. on the Abdomen-RUQ

3/15/2025 at 4:30 p.m. on the Abdomen-RUQ

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

During a record review of Resident 26's Face Sheet (FS - Admission Record), the FS indicated Resident 26 was originally admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), urinary tract infection (UTI - an infection in the bladder/urinary tract), and resistance to vancomycin (a medication used to treat infections).

During a record review of Resident 26's Minimum Data Set (MDS - resident assessment tool), dated 4/1/2025, the MDS indicated the resident was able to understand others and was able to make herself understood.

The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and mobility.

During a review of Resident 26's Physician Orders Sheet, the Physician Order Sheet indicated the following orders:

- Dated 3/15/2025 and discontinued on 3/18/2025, contact isolation precaution (an infection control intervention designed to reduce the transmission of infections that includes donning [putting on] gowns and gloves prior to entering a resident's room) for vancomycin-resistant enterococcus (VRE, a type of bacteria called enterococci that have developed resistance to many antibiotics, especially vancomycin) of urine.

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

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During a review of Resident 96's Minimum Data Set (MDS - resident assessment tool), dated 4/4/2025, the MDS indicated the resident was able to understand others and was able to make herself understood.

The MDS further indicated that the resident was dependent on staff for toileting and bathing, required substantial / maximal assistance for dressing and moving from lying to sitting, and required partial/moderate assistance for personal hygiene and rolling left and right in the bed.

During a review of Resident 96's History and Physical (H&P), dated 3/26/2025, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 96's Physician Order Sheet April 2025, dated 3/28/2025, the Physician Order Sheet indicated the following orders:

- On 3/25/2025, bupropion HCL XL (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] used to treat depression) 300 milligram (mg - a unit of measurement) 24-hour tablet, extended release, give one tablet daily at the a.m. medication (med) pass by mouth, for major depressive disorder manifested by sad facial expressions.

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

During a review of Resident 107s Face Sheet (Admission Record), the Face Sheet indicated the facility originally admitted the resident on 3/23/2020 and readmitted in the facility on 7/26/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarct (stroke, loss of blood flow to a part of the brain) affecting right dominant side, diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastrostomy status (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

During a review of Resident 107's History and Physical (H&P), dated 7/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 107's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2025, the MDS indicated Resident 107 had severely impaired cognition (mental action or process of acquiring knowledge and understanding).

The MDS further indicated Resident 107 required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).

During a review of Resident 107's care plan (CP) on potential for hypoglycemia (abnormally low level of sugar in the blood) or hyperglycemia (abnormally high level of sugar in the blood), initiated on 8/8/2024, the CP indicated to administer medications as ordered.

During a review of Resident 107's Physician's Order Sheet, dated 1/20/2025, the Physician Order Sheet indicated the following physician's order:

- Humulin R regular insulin (a short acting insulin) 100 unit per milliliter (unit/ml - a unit of measurement) injection solution four (4) times daily per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal):

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

During an observation on 5/8/2025 at 11:51 a.m., the first meal cart was delivered out in the cafe dining room.

During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) on 5/8/2025 at 11:52 a.m. of puree diet with [NAME] 1, [NAME] 1 stated the mixed vegetables puree did not fall off the spoon and there are still some left on the spoon. [NAME] 1 stated she checks the puree consistency by mixing clockwise and if she feels it's too thick then she would add more liquid when it's too watery she would add more thickener. [NAME] 1 stated she does not tilt the spoon and check if it falls off. [NAME] 1 stated she only mixes it that was all. [NAME] 1 stated that the puree mixed vegetables consistency was good even though not all the puree mixed vegetables fell off the spoon.

056084

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056084 B.

Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Nursing and Rehab Center 14040 Astoria Street Sylmar, CA 91342

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SYLMAR, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Astoria Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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