Astoria Healthcare Center

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool), accurately reflected the resident's medical diagnoses for one of four sampled residents (Resident 1). This deficient practice had the potential to delay the provision of necessary care and services to Resident 1 and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, dated 12/26/2025, the admission Record indicated the facility originally admitted Resident 1 on 7/2/2021, and readmitted on [DATE REDACTED] with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), dependence on renal dialysis, anemia (a condition where blood lacks enough healthy red blood cells to carry adequate oxygen to the body) and acute on chronic combined systolic and diastolic heart failure (a long-standing heart problem affecting both the heart's ability to pump (systolic) and relax/fill (diastolic), leading to fluid buildup and inefficient blood flow). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 8/11/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 had diagnoses of dementia (a progressive state of decline in mental abilities).

During a concurrent interview and record review on 12/26/2025 at 12:42 p.m. with the MDS Coordinator, Resident 1's MDS, dated [DATE REDACTED] was reviewed. The MDS indicated Resident 1 did not have diagnoses of dementia. The MDS Coordinator stated MDS diagnoses should reflect Resident 1's H&P provided by the primary physician. The MDS Coordinator stated the during the MDS assessment and documentation the facility staff should have reviewed Resident 1's H&P for potential new diagnoses such as dementia rather than reviewing Resident 1's diagnoses on the already existing admission Record (face sheet). The MDS Coordinator stated the failure to accurately update Resident 1's diagnoses in the MDS had the potential to delay Resident 1's care. During an interview on 1226/2025 at 2:31 p.m. with the Director of Nursing (DON),

the DON stated it is the MDS Coordinator's responsibility to review and update residents' diagnoses as needed. The DON stated Resident 1's diagnoses should be based on primary physician's notes and be reflective in Resident 1's MDS and Care Plan. The DON stated the MDS is the overall assessment of the resident's condition and should include all resident's diagnoses. The DON stated the failure to ensure MDS was accurate had the potential to delay care for Resident 1 due to inaccuracy of the assessment. During a

review of the current facility-provided policy and procedure titled, RAI Process, last reviewed on 6/19/2025,

the policy and procedure indicated, To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. C. All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Data (ARD).

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

12/26/2025

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 - Immediate jeopardy to resident health or safety Residents Affected - Few

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

medical, nursing, mental and psychosocial. A Licensed Nurse will initiate the Care Plan . and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. VIII. A Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

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

12/26/2025

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 0698 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

hemodialysis treatment. The DON stated facility staff failed to document when Resident 1 left and returned to the facility, failed to obtain vital signs, and failed to assess Resident 1's AV fistula site for bleeding upon her (Resident 1) return. The DON stated there was no documented evidence to indicate that Resident 1 was monitored after returning to the facility on [DATE REDACTED]. The DON stated facility staff did not follow the facility's policies and protocol related to the care and monitoring of a resident receiving hemodialysis and failed to implement Resident 1's Care Plan interventions for AV fistula care and monitoring following her (Resident 1) return from hemodialysis treatment. The DON stated, as a result, on [DATE REDACTED], Resident 1 experienced a hemorrhage (excessive bleeding) from the AV fistula site and passed away at 8:15 p.m. The DON stated the incident on [DATE REDACTED] could have been avoided if facility staff followed the facility's P&P for the care and monitoring of hemodialysis residents and implemented Resident 1's Care Plan (initiated on [DATE REDACTED]) interventions. During a concurrent interview and record review on [DATE REDACTED] at 3:08 p.m. with the DON, the facility's P&P tiled, Dialysis Care, dated [DATE REDACTED] was reviewed. The P&P indicated, The Facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment and providing for all non-dialysis needs of the resident including

during the time period when the resident is receiving dialysis. V. Documentation: A. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. B. Documentation may include NP-225-Form A-Pre/Post Dialysis Assessment, Form-225-Form-B-Dialysis Flow Sheet-Return Assessment. The DON stated the facility's P&P for Dialysis Care did not clearly define the pre- and post-dialysis responsibilities of licensed nurses, the required monitoring of the residents before and after dialysis treatment, and the care and monitoring of dialysis access sites. The DON stated that this lack of clarity resulted in confusion among facility staff regarding preand post-dialysis assessments, the care of residents receiving hemodialysis, and the proper implementation of care plan interventions. The DON further stated there was a systemic failure in the facility's processes for providing care to residents before and after hemodialysis treatment. During a review of the current facility-provided P&P titled, End-Stage Renal Disease, Care of a Resident with, last reviewed

on [DATE REDACTED], the P&P indicated, Residents with (ESRD) will be cared for according to currently recognized standards of care. 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: . b. the type of assessment data that is to be gathered about the residents' condition on a daily or per shift basis; . g. the care of grafts (is a surgically implanted, soft, synthetic tube used to connect an artery and a vein, typically in the arm) and fistulas. 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a review of

the current facility-provided P&P titled, Documentation-Nursing, last reviewed on [DATE REDACTED], the P&P indicated, To provide documentation of resident status and care given by nursing staff. Nursing documentation will be concise, clear, pertinent, and accurate. G. Nurse's notes addressing the resident leaving the facility will document when and with whom, and time of return, along with any medications sent.

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

12/26/2025

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

assistants are trained and must demonstrate competence in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities.5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions. The DON stated the P&P for Staffing, Sufficient and Competent Nursing, was not followed.

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

12/26/2025

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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. resident census data from the previous 12 months; b. resident capacity of the facility and its occupancy rate for the past 12 months; c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with: . (5) conditions or diseases that require specialized care (example given dialysis.).4. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes the following: . f. A breakdown of the training, licensure, education, skill level and measures of competency for all personnel; g. The current status of health information technology, including: (1) electronic health records; (2) electronic exchange of information with other organizations; and (3) personnel access to devices and equipment, internet and other tools.6. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the quality assurance and performance improvement evaluation.

Event ID:

Facility ID:

If continuation sheet