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Complaint Investigation

Astoria Healthcare Center

November 21, 2025 · Sylmar, CA · 14040 Astoria Street
Citations 4
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 November 21, 2025.

Found 4 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

FF0607
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

tried to steal Resident 2's things and he (Resident 2) just defended himself (Resident 2).

The COC indicated no injuries and no pain.

The COC indicated the physician was notified on 11/9/2025, at 9:43 p.m.During a concurrent interview, and record review on 11/14/2025, at 12:51 p.m., with the Assistant Director of Nursing (ADON), facility's Witness Statements, dated 11/10/2025, were reviewed.

The ADON stated she (ADON) had called and interviewed Registered Nurse 1 (RN 1), Licensed Vocational Nurse 1 (LVN 1) and LVN 2.

The ADON stated the Witness Statement was not signed and dated.

The ADON stated Certified Nursing Assistant 1 (CNA 1) was the first staff to witness the altercation.

The ADON stated she (ADON) did not have a copy of CNA 1's witness statement.

The ADON stated the Director of Staff development (DSD) or RN 1 might have a copy of CNA 1's witness statement.

During an interview on 11/14/2025, at 1:02 p.m., with CNA 1, CNA 1 stated she (CNA 1) had written a Witness Statement and gave it to RN 1.

During an interview on 11/14/2025, at 1:09 p.m., with RN 1, RN 1 stated she (RN 1) had asked CNA 1 to write a witness statement, and she (RN 1) had transcribed the written statement in the electronic medical record. RN 1 stated CNA 1's written statement was on her (RN 1) locker. RN 1 stated she (RN 1) was not sure if their policy was to submit a written signed statement.

During an interview on 11/14/2025, at 1:44 p.m. with the ADON, the ADON stated she (ADON) did not ask the staff (RN 1, LVN 1 and LVN 2) to write their statements.

The ADON stated after interviewing the staff (RN 1, LVN 1 and LVN 2) she (ADON) documented it and gave each staff (RN 1, LVN 1 and LVN 2) a copy of the statement.

The ADON stated she (ADON) did not know that staff had to sign and date the Witness Statements.

The ADON stated she (ADON) was not familiar with their policy and procedure (P&P) that witnesses had to sign and date their statements.During a concurrent interview, and record review of the facility's P&P titled, Abuse Investigations, dated 4/1010, and last reviewed on 6/19/2025, the P&P indicated, Witness reports will be obtained in writing.

Witnesses will be required to sign and date such reports.

The DON stated the P&P was not followed.

The DON stated the facility had interviewed the witnesses and documented the interviews.

The DON stated the ADON should have asked the witnesses to date and sign the Witness Statements.

During an interview on 11/18/2025, at 11:58 a.m., with the DON, the DON stated because there were no signed and dated Witness Statements, it gave an inaccurate detail of the incident, could cause a delay in the investigations and potentially place Resident 1 and Resident 2 at risk for possible abuse.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

SUMMARY STATEMENT OF DEFICIENCIES

Registered Dietitian (RD), the RD stated Resident 4 can feed herself (Resident 4) but also needs assistance.

The RD stated she (RD) had recommended staff to provide assistance with setting up the tray and assistance with feeding.

The RD stated if feeding assistance was not provided to Resident 4, Resident 4 could generally decline and experience weight loss and dehydration.

The RD stated she (RD) was aware that Resident 4 had refused feeding assistance.

During an interview on 11/18/2025, at 10:04 a.m., with the Director of Staff Development (DSD), the DSD stated CNA 2 should have reported Resident 4's refusal of feeding assistance so nurses can develop a care plan to address residents' refusal.

The DSD stated without the care plan, Resident 4 could have weight loss.

During an interview on 11/18/2025, at 11:58 a.m., with the Director of Nursing (DON), the DON stated CNA 2 should report resident refusal with feeding assistance so nurses can develop a care plan.

The DON stated care plan list the interventions to prevent Resident 4's weight loss from refusal of assistance.During a review of facility's policy and prevention (P&P), titled, Care Planning, dated 10/1/2023 and last reviewed on 6/19/2025, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.IX.

Each resident's Comprehensive Care Plan will describe the following:A.

Services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being;B.

Any services that would be required but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

SUMMARY STATEMENT OF DEFICIENCIES

DocumentationA.

The CNA will document the care provided on the facility's method of documentation, manually or electronic.B.

The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed.C.

Documentation will be completed by the end of the assigned shift.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 4) by failing to follow Resident 4's physician order.This failure had the potential to result in Resident 4 experiencing hypotension (low blood pressure).Findings:During a review of Resident 4‘s admission Record, the admission Record indicated the facility admitted Resident 4 on 5/27/2013, with diagnoses that included unspecified (unconfirmed) heart failure (when the heart muscle does not pump blood as well as it should), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 4's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/16/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's Order Summary Report, dated 6/28/2025, the Order Summary Report indicated hydralazine hydrochloride (medication used to lower blood pressure) oral tablet 10 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every 12 hours for hypertension (HTN-high blood pressure).

Hold for systolic blood pressure (sbp-the top/upper number. It measures the pressure of the blood pushing against the artery walls when the heart beats) less than 110 millimeters of mercury (mmHg- it indicates the level of pressure or compression) or if heart rate is less than 60 beats per minute (bpm).During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 9/25/2025, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 4's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 11/2025, the MAR indicated on 11/8/2025, at 9 p.m., Licensed Vocational Nurse 3 (LVN 3) gave hydralazine to Resident 4 who had a blood pressure of 100/67 mmHg.During a concurrent interview, and record review on 11/18/2025, at 10:04 a.m., with the Director of Staff Development (DSD), Resident 4's Order Summary Report, dated 6/28/2025, and MAR, dated 11/8/2025, was reviewed.

The DSD stated LVN 3 should have held the hydralazine because Resident 4's blood pressure was below 110 mmHg.

The DSD stated LVN 3 should have followed the physician's order.

The DSD stated Resident 4 could experience hypotension after LVN 3 gave the hydralazine.During an interview on 11/18/2025, at 11:58 a.m. with the Director of Nursing (DON), the DON stated LVN 3 should have followed the physician's order to hold the hydralazine for blood pressure below 110 mmHg.

The DON stated Resident 4's could experience dizziness, hypotension and could possibly lead to Resident 4's death.During a review of facility's policy and procedure (P&P), titled, Medication Administration dated 10/1/2023, and last reviewed on 6/19/2025, the P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.

Facility ID:

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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