Astoria Healthcare Center

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Astoria Healthcare Center

14040 Astoria Street Sylmar, CA 91342

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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.

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Facility ID:

If continuation sheet