Astoria Nursing And Rehab Center
Inspection Findings
F-Tag F656
F-F656
.
Findings:
a. During a review of Resident 1's Face Sheet (Admission Record), the Face Sheet indicated the facility admitted Resident 1 on 4/22/2025, with diagnoses that included unspecified (unconfirmed) fracture of the ninth and tenth thoracic vertebrae (a break in the bone of the spine, specifically in the middle back), history of fall, and unspecified dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Tool (a technique that provides a framework for communication between members of the health care team about a resident's condition), dated 4/23/2025, the SBAR indicated on 4/23/2025 at 6:45 a. m., Resident 1 was found sitting on her (Resident 1) bedside floor with a pain level of 10 out of 10 (zero-no pain, 10-severe pain) right shoulder and right arm pain.
During a review of Resident 1's Patient Report (Radiology Report-a detailed report that describes the results of an imaging test), dated 4/23/2025, the Patient Report indicated Resident 1 had acute mildly displaced fracture (a bone break that occurred recently within the first few days and where the broken pieces of bone are slightly out of alignment) involving the proximal humerus (the upper, shoulder end of the humerus bone, which is the long bone in the upper arm).
During a review of Resident 1's Care Plan, dated 4/23/2025, about status post (after) fall, the Care Plan indicated an intervention initiated on 4/25/2025 for Resident 1 to have a bed alarm while Resident 1 was in bed.
During a review of Resident 1'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) Examination, dated 4/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 056084 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Nursing and Rehab 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 0689 During a review of Resident 1's Care Plan Review, dated 4/25/2025, the Care Plan Review indicated an Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) Level of Harm - Minimal harm or meeting was done with Family member 1 (FM 1) about Resident 1's fall incident on 4/23/2025. The Care potential for actual harm Plan Review indicated FM 1 agreed for Resident 1's use of bed alarm.
Residents Affected - Few During a concurrent observation, and interview on 4/29/2025, at 8:15 a.m., with Resident 1, at Resident 1's bedside. Observed Resident 1 raised her buttocks and waist from her (Resident 1) bed and heard no sound of an alarm. Resident 1 stated she (Resident 1) had a bed alarm, but it was off today (4/29/2025) and was not working. Resident 1 stated she did not remember where she (Resident 1) fell but knows it was on her right side because she (Resident 1) had a broken right shoulder.
During an interview on 4/29/2025, at 8:35 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 did not have a bed alarm.
During an interview on 4/29/2025, at 8:46 a.m., with Certified nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 had no bed alarm.
During a concurrent observation and interview on 4/29/2025, at 9 a.m., with the Director of Staff Development (DSD), in Resident 1's right side of the bed. Observed a blue machine box hanging on the right side of the bed with no light on. The DSD stated the bed alarm was not turned on. The DSD stated the wire from the sensor pad (pressure-sensitive devices designed to detect weight, that is placed under a mattress or a chair. When pressure is removed or when someone gets up from a bed, the pad sends an alert), was not connected to the bed alarm machine. Observed the DSD connected the sensor pad wire to the bed alarm machine and a small light on the bed alarm machine turned green and made a beeping sound.
During an interview on 4/29/2025, at 9:33 a.m., with LVN 1, LVN 1 stated he (LVN 1) should have checked and made sure that Resident 1's bed alarm was turned on and functioning. LVN 1 stated the importance of bed alarm was for Resident 1's safety, to prevent another fall.
During an interview on 4/29/2025, at 9:40 a.m., with the DSD, the DSD stated CNAs, LVNs and nurses are responsible for making sure bed alarm are functioning to prevent Resident 1's fall.
During an interview on 4/29/2025, at 10:36 a.m., with the Director of nursing (DON), the DON stated bed alarm alerts the staff for any unsupervised attempts of Resident 1 to get up from the bed to prevent fall. The DON stated if bed alarm was not turned on and not working the risk of Resident 1 falling again can happen.
The DON stated nurse should check the bed alarm if its working.
During a review of facility's policy and procedure (P&P) titled, Using Devices as Nursing Intervention, undated and last reviewed on 1/16/2025, the P&P indicated, It is the policy of this facility to use device(s) to remind resident to call for assistance when needed and not to get up from bed or wheelchair unassisted. Some devices are being used as enabler or intervention to protect resident from sustaining major injury. Devices are defined as a manual method or physical or mechanical device material, or equipment attached or adjacent to the resident 's body that the resident can remove easily by merely asking to avoid restriction of movements. Some devices are placed around resident's bed or wheelchair as a nursing intervention to protect resident for possible injury.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 056084 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Nursing and Rehab 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 0689 b. During a review of Resident 1's Fall Risk assessment dated [DATE REDACTED], the Fall Risk Assessment indicated Resident 1 had a total score of eight (low risk for fall, 10 represents high risk for fall). The Fall Risk Level of Harm - Minimal harm or Assessment indicated Resident 1 had one or two of the condition listed was present and scored two points potential for actual harm on predisposing diseases (a condition that increases a person's risk of developing another, related disease).
The Fall Risk Assessment indicated the following predisposing conditions: 1. hypertension (HTN-high blood Residents Affected - Few pressure),
2. vertigo (a sensation of spinning or movement),
3. cardiovascular accident (CVA- stroke, loss of blood flow to a part of the brain),
4. Parkinson's diseases (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements),
5. loss of limbs,
6. seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness),
7. arthritis (inflammation or swelling of one or more joints)
8. osteoporosis weak and brittle bones due to lack of calcium and Vitamin D) and
9. fractures.
During a concurrent interview and review on 4/29/2025 at 9:40 a.m., with the DSD, Resident 1's Fall Risk assessment dated [DATE REDACTED] was reviewed. The DSD stated Resident 1 was not a high risk for fall because Resident 1's total score was below 10. The DSD stated Resident 1's Fall Risk assessment dated [DATE REDACTED] should be high risk for fall.
During an interview on 4/29/2025, at 10:36 a.m., with the DON, the DON stated Resident 1's Fall Risk Assessment should be high risk for fall because Resident 1 had history of fall, HTN, osteoporosis and fracture. The DON stated Resident 1 had four predisposing condition for fall. The DON stated the Fall Risk Assessment, dated 4/23/2025 was incorrect. The DON stated because of incorrect Fall Risk Assessment, intervention was inaccurate, and the facility will not be able to implement necessary intervention specific to Resident 1. The DON stated safety measure will not be implemented that can jeopardize (place in danger) resident safety. The DON stated the Registered Nurse (RN) should have assess Resident 1 thoroughly and
review the H&P and diagnoses of Resident 1 before completing the Fall Risk Assessment.
During a review of facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, dated 3/2018, and last reviewed on 1/16/2025, the P&P indicated, Assessment and Recognition:
1. The physician will help identify individuals with a history of falls and risk factors for falling.
a. Staff will ask the resident and the caregiver or family about a history of falling.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 056084 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Nursing and Rehab 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 0689 2. In addition, the nurse shall assess and document/report the following:
Level of Harm - Minimal harm or a. Vital signs (are measurements of basic bodily functions that indicate overall health), potential for actual harm b. Recent injury, especially fracture or head injury. Residents Affected - Few c. Musculoskeletal function, observing for change in normal range of motion (ROM-the extent of movement a joint can make in a particular direction), weight bearing,
d. Change in cognition or level of consciousness (a person's state of awareness and understanding of their surroundings).
e. Neurological status.
f. Pain.
g. Frequency and number of falls since last physician visit.
h. Precipitating factors (events or conditions that trigger or initiate a specific outcome, often a crisis or a significant change in behavior or state), details on how fall occurred.
i. All current medications, especially those associated with dizziness or lethargy (sleepiness); and
j. All active diagnoses.
3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record.
a. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy (a condition where the peripheral nerves, those outside the brain and spinal cord, are damaged), gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension (low blood pressure), and medical conditions affecting the central nervous system (brain and spinal cord).
4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant [medication used to prevent blood clot]).
Treatment/Management
I. Based on the preceding assessment. the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 056084
F-Tag F689
F-F689
.
Findings:
During a review of Resident 1's Face Sheet (Admission Record), the Face Sheet indicated the facility admitted Resident 1 on 4/22/2025, with diagnoses that included unspecified (unconfirmed) fracture of the ninth and tenth thoracic vertebrae (a break in the bone of the spine, specifically in the middle back), history of fall, and unspecified dementia (a progressive state of decline in mental abilities).
During a review of Resident 1'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) Examination, dated 4/25/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Care Plan, dated 4/23/2025, about status post (after) fall, the Care Plan indicated an intervention initiated on 4/25/2025 for Resident 1 to have a bed alarm while Resident 1 was in bed.
During a review of Resident 1's Care Plan Review, dated 4/25/2025, the Care Plan Review indicated an Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) meeting was done with Family member 1 (FM 1) about Resident 1's fall incident on 4/23/2025. The Care Plan Review indicated FM 1 agreed for Resident 1's use of bed alarm.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 056084 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Nursing and Rehab 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 During a concurrent observation, and interview on 4/29/2025, at 8:15 a.m., with Resident 1, at Resident 1's bedside. Observed Resident 1 raised her buttocks and waist from her (Resident 1) bed and heard no sound Level of Harm - Minimal harm or of an alarm. Resident 1 stated she (Resident 1) had a bed alarm, but it was off today (4/29/2025) and was potential for actual harm not working.
Residents Affected - Few During an interview on 4/29/2025, at 8:35 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was not on bed alarm.
During an interview on 4/29/2025, at 8:46 a.m., with Certified nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 had no bed alarm.
During a concurrent observation, and interview on 4/29/2025, at 9 a.m., with the Director of Staff Development (DSD), in Resident 1's right side of the bed. Observed a blue machine box hanging on the right side of the bed with no light on. The DSD stated the bed alarm was not turned on. The DSD stated the wire from the sensor pad was not connected to the bed alarm machine. Observed the DSD connected the wire to
the bed alarm machine and a small light on the machine turned green and heard a beeping sound.
During an interview on 4/29/2025, at 9:33 a.m., with LVN 1, LVN 1 stated he (LVN 1) should have checked and made sure that Resident 1's bed alarm was turned on and functioning. LVN 1 stated the importance of care plan was it guides the nurses on Resident 1's care, how to manage and treat Resident 1 to achieve Resident 1's goal and for Resident 1's safety.
During an interview on 4/29/2025, at 9:40 a.m., with the DSD, the DSD stated CNAs, LVNs and nurses are responsible for making sure bed alarm are functioning for Resident 1's to prevent fall.
During a concurrent interview, and record review on 4/29/2025, at 10:36 a.m., with the Director of Nursing (DON), facility's policy and procedure (P&P) titled, Comprehensive Care Plan undated and last reviewed on 1/16/2025, the P&P indicated, 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address
the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. 6. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task
in isolation. The resident's physician (or primary healthcare provider) is integral to this process. The DON stated Resident 1's care plan for use of bed alarm should be followed. The DON stated care plans are guides on how to render necessary care to Resident 1 and bed alarm was one of the intervention to prevent Resident 1's fall.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 056084 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
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 04/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Nursing and Rehab 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42311
Residents Affected - Few Based on observation, interview, and record review, the facility failed to follow its policy on fall prevention for one of three sampled residents (Resident 1) who had a history of fall and had an incident of fall on 4/23/2025 while admitted at the facility by:
1. Failing to ensure Resident 1's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was turned on and functioning.
2. Failing to accurately assess Resident 1's Fall Risk Assessment after incident of fall on 4/23/2025.
These failures can potentially place Resident 1 at risk for further injury, fall, and accidents.
Cross reference