Other·July 25, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the Recertification survey and investigation of four Facility Reported Incidents (FRI). FRI number: CA00625209, CA00638197, CA00637424, CA00640266. Representing the Department of Public Health: Surveyor ID No. 27679, RN, HFEN Surveyor ID No. 33636, RN, HFEN Surveyor ID No. 34659, RN, HFEN Surveyor ID No. 40732, RN, HFEN Surveyor ID No. 40994, Pharmacist Consultant One deficiency was issued for FRI CA00625209, refer to F656. One deficiency was issued for FRI CA00638197, Refer to F689 . Five deficiencies were issued for FRI CA00637424, Refer to F578, F645, F695,

F842, and F657. No deficiencies were issued for CA00640266. Total Population: 163 Sample Size: 55 Highest Severity and Scope: G

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 07/22/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 1 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the resident's medical records were updated to show documentation that advance directives (written statement of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 2 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the resident and/or responsible parties for one of four sampled residents (Resident 128). This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate their advance directives. Findings: A review of Resident 128's Admission Record indicated the resident was originally admitted to the facility on January 23, 2017, and readmitted on March 16, 2019, with diagnoses of, but not limited to, muscle weakness and seizure disorder (a medical condition that is characterized by episodes of uncontrolled electrical activity in the brain). A review of Resident 128's Minimum Data Set (MDS- a standardized assessment and screening tool) dated May 22, 2019, indicated that Resident 128's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated the resident is totally dependent on staff for locomotion off and on unit, and toilet use. A review of Resident 128's record indicated no specification of code status (the level of medical interventions a resident wishes to have started if their heart or breathing stops) written FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 3 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on either Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records residents' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration) form or on advance directive. There was no documented evidence of advance directives were discussed. On June 6, 2019, at 9:55 a.m., at a concurrent record review and interview, the Director of Nursing (DON) stated if resident comes in with advance directives, the facility files the form, if not, the facility uses POLST form. However, the DON was not able to find neither advance directive form nor POLST. The DON stated that the social service department is responsible to fill out the POLST form within 48 hours of admission and file it in the medical chart (record). On June 6, 2019, at 10:10 a.m., during a record review and interview with Social Services Director (SSD), the SSD confirmed that there is no documentation of POLST or advance directive in Resident 128's clinical (medical) records and there is no documented evidence that written information was provided to Resident 128's responsible party regarding the right to formulate an advance directive. The POLST Form is a set of medical orders, similar to the do-not resuscitate (allow natural death) order. POLST is not an advance directive. POLST does not substitute for naming a health care agent or durable power of attorney for health care. The POLST Form is completed as a result of the process of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 4 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE informed, shared decision-making. During the conversation, the resident discusses his or her values, beliefs, and goals for care, and the health care professional presents the resident's diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment. Together they reach an informed decision about desired treatment, based on the person's values, beliefs and goals for care. (POLST.org) A review of the facility's policy and procedure dated April 2008, titled "Advance Directives," indicated that prior to or upon admission, the Social Services Director or designee will provide written information to the resident concerning the right to make decisions, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

F636 SS=D Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 07/22/2019 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 5 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 6 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS- an assessment and care screening tool) assessment in a timely manner for one of one resident investigated for the facility task Resident Assessment (Resident 1). This deficient practice had the potential to delay delivery of necessary care and services for Resident 1. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on July 27, 2004, with diagnoses that included, but was not limited to, gastro-esophageal reflux disease (GERDstomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), hypertension (high blood pressure), aphasia (impairment of language), and atrial fibrillation (irregular rapid heart rate). A review of Resident 1's Minimum Data Set dated April 30, 2019, indicated resident has a Brief Interview for Mental Status (BIMS- a screening tool to determine cognitive impairment) score of 9. A score of 8-12 indicates moderately impaired cognition) and has the ability to sometimes make selfunderstood and the ability to usually understand others. During a concurrent interview and record review, on June 7, 2019, at 12:21 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 7 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Minimum Data Set Nurse 2 verified that Resident 1's last MDS was done on January 8, 2019, and was a quarterly assessment. MDS Nurse 2 stated that the next MDS should have been completed on April 8, 2019, which was supposed to be Resident 1's annual assessment. MDS Nurse 2 confirmed that Resident 1's annual MDS was not completed and the last annual MDS that was completed was on April 8, 2018. MDS Nurse 2 stated that the computer system did not notify them that the MDS was to be completed. During an interview on June 10, 2019, at 2:46 p.m., MDS Nurse 1 confirmed that Resident 1's annual MDS was not completed and was overdue. MDS Nurse 1 stated that she spoke with MDS Nurse 2 about having a manual list of residents in writing with MDSs that are to be reviewed and updated for quarterly and annual assessments. A review of the facility's policy and procedure titled, "Resident Assessment Instrument," revised on October 2010, indicated, "The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: within 14 days of the resident's admission to the facility; when there has been a significant change in the resident's condition; at least quarterly; and once every 12 months."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 07/22/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 8 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to accurately assess the psychosocial needs of one of five sampled residents (17) by failing to list anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) in the Minimum Data Set (MDS - a comprehensive resident assessment tool.) The failure to include pertinent diagnoses such as anxiety disorder in the comprehensive resident assessment increased the risk that Resident 17's psychosocial needs may not have been fully addressed or treated resulting in a negative impact to her health and wellbeing. Findings: On 06/06/19, at 08:46 AM, during a record review, Resident 17's clinical (medical) record indicated that she was initially admitted to the facility on 8/30/18, with diagnoses including, but not limited to: major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder. A review of the Resident 17's face sheet (a document with demographic and diagnostic information about the resident) did not list anxiety disorder among her active diagnoses, however, a review of the psychiatry consult note dated 10/22/18, listed anxiety disorder among the resident's psychiatric diagnoses. Review of Section I (active diagnoses) of the MDS assessment dated 3/7/19, indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 9 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility staff had assessed Resident 17 as NOT having anxiety disorder, however, previous assessments done on 9/6/18, and 12/7/18, both indicated that she did have anxiety disorder. On 06/06/19, at 10:49 AM, during an interview, Minimum Data Set Nurse 3 (MDS Nurse 3) stated that Resident 17's comprehensive assessment from 3/7/19, is not coded correctly, because the MDS indicates that she does not have anxiety disorder despite the previous assessments indicating that she does. MDS Nurse 3 stated that the reason that the comprehensive assessment dated 3/7/19, is coded incorrectly is because, when she performed the assessment, the diagnoses of anxiety disorder was not in the diagnosis list within the facility's computer system, and thus did not auto-populate into the comprehensive assessment template. MDS Nurse 3 stated that she failed to review the chart (medical record) to add the diagnosis both to Resident 17's diagnosis list and to the comprehensive assessment on 3/7/19. MDS Nurse 3 stated that she will correct the comprehensive assessment of 3/7/19 and add the diagnosis in the computer system, so that future comprehensive assessments accurately reflect the resident's active diagnoses. A review of the facility policy titled "Resident Assessment Instrument" revised October 2010, indicated that "The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity" and "Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning."

F645 SS=D PASARR Screening for MD & ID CFR(s): 483.20(k)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F645 Event ID: 2WPU11 07/22/2019 Facility ID: CA920000002 If continuation sheet 10 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k) (3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 11 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b) (3) or is a person with a related condition as described in 435.1010 of this chapter. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the clinical (medical) records were accurately documented for one of one sampled resident (Resident 128) by failing to accurately enter correct data in the Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) form in a timely manner. This deficient practice resulted in inaccurate medical care information and placed Resident 128 at risk for not getting necessary care related to special services for intellectual FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 12 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disabilities. Findings: A review of Resident 128's Admission Record indicated the resident was originally admitted to the facility on January 23, 2017, and readmitted on March 16, 2019, with diagnoses of, but not limited to, muscle weakness and seizure disorder (a medical condition that is characterized by episodes of uncontrolled electrical activity in the brain). A review of Resident 128's Minimum Data Set (MDS- a standardized assessment and screening tool) dated May 22, 2019, indicated that Resident 128's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated the resident is totally dependent on staff for locomotion off and on unit, and toilet use. At a concurrent review of Resident 128's PASRR and interview on June 6, 2019, at 9:55 a.m., the Director of Nursing (DON) stated that Resident 128 has intellectual disabilities, so PASRR Section 6 should have been answered as YES, to number 31, 32, 33, 34, 35, and 36. The DON stated that MDS nurse filled it out and the form needs to be revised. On June 10, 2019, at 2:52 p.m., at a concurrent record review of Resident 128's PASRR and interview, MDS Nurse 3 stated that she assesses PASRR upon resident's admission and she reviewed information entered on March 17, 2019, by another MDS nurse. MDS Nurse 3 stated that section two, number 15 should be checked as No, number 17a as No, 19a as Yes, 19b as Yes; Section five number FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 13 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 26 as yes with diagnoses of depression and psychosis, number 29 as unknown; Section six number 31 as Yes, 32 as unknown, 33 as Yes, 34 as unknown, 35 as Yes, 36 as Yes, requires total assist with Activities of Daily Living (ADLs). A review of the facility's policy and procedure dated January 2004, titled "Preadmission Screening and Resident Review," indicated PASRR DHS 6170 evaluation form shall be completed either prior to admission or on the first day for which Medicaid reimbursement is requested. This shall be completed, using the Department of Health Services PAS/PASRR manual by either admission coordinator or nursing staff.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/22/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 14 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two of six sampled residents (Resident 131, 7) to meet the residents' medical, nursing, and mental and psychosocial needs by: 1. Failing to implement the comprehensive care plan for resident (Resident 131) by failing to arrange for regular psychiatric follow-up care. The deficient practice of failing to arrange psychiatric care in accordance with the care plan increased the risk that Resident 131's health and well-being could be negatively impacted due to lack of follow-up care necessary to continually assess her behavioral needs and medications used to manage them. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 15 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Failing to address Resident 7's diagnosis of osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D) to include, the potential for fractures due to osteoporosis, daily requirement of vitamin D and Calcium, and monitoring Resident 7's vitamin D level to determine the effectiveness. These deficient practices resulted in a delay of determining the continued need for vitamin D 3, necessary to promote strengthening of Resident 7's bones, and can lead to an increased risk for fractures. Findings: a. On 06/06/19, at 01:38 PM, during a record review, Resident 131's clinical (medical) record indicated that she was originally admitted to the facility on 12/25/17, with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning), psychosis (a mental disorder characterized by a disconnection from reality), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) A review of Resident 131's physician order dated 1/18/18, indicated that she was taking risperidone (a medication used to treat mental illness) 0.5 milligram (mg) every day for "psychotic disorder manifested by striking out with caregiver." A review of Resident 131's physician order date 2/21/18, indicated that she was supposed to receive "psychiatric evaluation and treatment consult." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 16 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 131's care plan titled "Anti-Psychotic Drug Therapy" dated 12/25/17, indicated that because the resident was prescribed risperidone to manage her behavior of "striking out with caregiver" she was to receive "psychiatric consult as needed" as a care planned intervention. Further review of Resident 131's clinical record indicated that the only psychiatric consult the resident had received, was prior to her admission to the facility on 11/29/17. No other record of psychiatric follow-up care could be found within the clinical record. On 06/06/19, at 02:44 PM, during an interview, the director of nursing (DON) stated that she knew that Resident 131 has to "go out" for her psychiatric evaluations due to her insurance requirements, but that she cannot find any other psychiatric consult notes or evidence of follow-up psychiatric care since the initial evaluation on 11/29/17. On 06/06/19, at 03:20 PM, during an interview, Social Services Director 1 (SSD 1) stated that she is "mostly" the one responsible for arranging psychiatric visits for the facility's residents. SSD 1 stated that Resident 131 has not had any psychiatric follow-up visits since the initial psychiatric evaluation done on 11/29/17. On 06/07/19, at 08:18 AM, during an interview SSD 1 stated that when residents are on psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors), the attending physicians will ask for referrals for psychiatric care to be provided by a psychiatrist. SSD 1 stated that because of Resident 131's insurance, a referral was required for her to be able to see a psychiatrist, and that the facility only recently (May 2019) received an approval FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 17 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from her insurance plan for her to see a psychiatrist. On 06/07/19, at 11:13 AM, during an interview, SSD 1 stated that Resident 131's insurance does not limit the number of psychiatrist visits she can receive once the referral is approved. SSD 1 stated that the first referral request was placed in May of 2018, and per the insurance plan, was authorized two days later. SSD 1 stated that the facility's business office claims that they never received any notification of the authorization. SSD 1 stated that she failed to follow up with Resident 131's insurance plan or the facility's business office to determine the outcome of the referral request and thus the resident's need for psychiatric care "fell through the cracks" for nearly a year. SSD 1 stated that the need for psychiatric care was not reassessed until April 23, 2019. SSD 1 stated that once they received notification of the insurance approval on 5/22/19, Resident 131's attending physician called in an order for the resident to see a psychiatrist for follow-up care and then she made an appointment. A review of the facility's undated policy titled "Social Services Department" indicated that "Social Services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered through the physician." b. A review of the admission record indicated Resident 7 was admitted to the facility on August 13, 2010, and readmitted on February 20, 2019, with diagnoses that included osteoarthritis (degeneration of joint cartilage and the underlying bone, and causes pain and stiffness, especially in the hip, knee, and thumb joints) and disorder of bone density and structure (otherwise known as osteoporosis). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 18 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 7's Physician's Progress Note dated January 26, 2011, indicated Resident 7 had a diagnosis of osteopenia (The difference between osteopenia and osteoporosis is that in osteopenia the bone loss is not as severe as in osteoporosis. That means someone with osteopenia is more likely to fracture a bone than someone with a normal bone density, but is less likely to fracture a bone than someone with osteoporosis. Having osteopenia does increase a person's chances of developing osteoporosis). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and carescreening tool), dated August 11, 2018, indicated Resident 7 was moderately impaired in cognitive status (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decisionmaking. The MDS indicated the resident was totally dependent (full staff performance every time during entire 7- day period) with twoperson extensive assistance for transfer. Resident 7 required extensive one-person assistance with dressing and toilet use. Resident 7 had a care plan for osteoporosis, dated August 11, 2018. Resident 7 did not have a Care Area Assessment (CAA) for osteoporosis for August 11, 2018. A review of 7's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated March 1, 2019, indicated Resident 7 remained moderately impaired in cognitive status in skills for daily decision-making. The MDS indicated the resident remained totally dependent (full staff performance every time during entire 7- day period with two-person extensive assistance for transfer. Resident 7 required extensive one-person assistance with dressing and toilet use. Resident 7's MDS indicated the resident had a diagnosis of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 19 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE osteoporosis without current pathological fracture. A review of Resident 7's Physician's Orders indicated the following: 1. Mechanical soft NAS (no added salt) diet, dated November 9, 2017. 2. Resource Plus (a nutrition drink) 4 ounces (oz) two times a day, dated March 16, 2018. 3. Vitamin D 3 2000 International Units (IU) by mouth every day, dated February 21, 2018. 4. Draw a Vitamin D 3 25 Hydroxy level (a laboratory blood test to monitor vitamin D levels), now, dated June 6, 2019. 5. Multivitamins with minerals 1 tab (tablet) by mouth every day for supplement, dated April 25, 2016. A review of Resident 7's Care Plan for Risk for deformities and pain related to osteopenia, initiated August 11, 2018, indicated a goal that Resident 7 will have no fall incidents in the next 3 months. One of the interventions on the preprinted form listed Calcium supplementation therapy as ordered. The Calcium intervention was not checked (indicated) as an intervention for Resident 7. There were no other interventions that included other supplementation therapy. A review of Resident 7's Care Plan for Risk for Spontaneous/Pathological Fracture related to osteoporosis and osteoarthritis, initiated August 11, 2018, indicated a goal that Resident 7 will have no signs and symptoms of fracture daily for 3 months. The care plan interventions indicated to give the resident medication as ordered, to monitor effect of medication, and inform doctor if medication is ineffective. The care plan did not specify which medication was to be monitored, how to monitor and when to monitor the medication, and did not list FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 20 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reference range parameters of when to inform the doctor if the medication was ineffective. Resident 7's Care Plan for Risk for Spontaneous Fracture related to osteoporosis and osteoarthritis, indicated Resident 7 will be able to move extremities without discomfort for 90 days. The care plan did not indicate the need for Vitamin D or Calcium (in the form of food or medication.) A review of Resident 7's Nutritional Screening and Assessment, dated September 10, 2018, indicated Resident 7 consumed 50% of her meals. A review of Resident 7's Nursing Assistant Daily Flow Sheets for October 2018, through February 2019, indicated Resident 7 consumed, on average 50% of her meals. A review of Resident 7's X-ray Report, dated February 18, 2019, indicated Resident 7 suffered a right proximal (situated nearer to the center of the body) femur (thigh bone) fracture (a broken hip). A review of Resident 7's Care Plan for Risk for Spontaneous Pathological Fracture related to Osteoporosis, initiated February 21, 2019, indicated Resident 7 would have Vitamin D 3 2000 IU by mouth daily. The intervention included to monitor effect of medication and inform the doctor if the medication is ineffective. There was no indication of which specific lab (laboratory) to monitor, when to monitor, and did not list reference range parameters of when to inform the doctor if the medication was ineffective. A review of Resident 7's Nutritional Screening and Assessment, dated February 26, 2019, indicated there was a significant change secondary to fracture, which was why the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 21 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident was sent to a general acute care hospital (GACH) and returned without any changes to dietary regimen. The assessment indicated Resident 7's meal consumption is less than 50% of what is offered. The assessment did not specify the resident's daily vitamin or mineral requirements related to the diagnosis of osteoporosis. A review of the facility's Spring 2019, Menu Nutrient Analysis (a chart that indicates how much vitamins and minerals are in the diet each day) but also applies to Fall/Autumn menu of 2018, indicated a No Added Salt (NAS) diet (Resident 7's diet) indicated the daily amount of Vitamin D in the food was 10.1 micrograms (mcg) (reference range for osteoporosis requirement is 20 mcg). The chart indicated the Calcium content was 1307 milligrams (mg) (reference range for osteoporosis is 1000 - 1200 mg). In an interview, the Dietary Director (DD) stated Resident 7 also receives Calcium and Vitamin D, in the nutrition drink that is in addition to Resident 7's meals. Resident 7 consumed 50% of her meals for October 2018, through February 2019, and based on the amount of the resident's intake, the resident received 10 mcg of Vitamin D and 650 mg of Calcium a day. A review of Resident 7's Nutrition Notes made by the Dietary Director (DD) from September 2018, through June 2019, did not indicate any daily vitamin or mineral requirements for Resident 7, to address the resident's osteoporosis. A review of Resident 7's Nutrition Drink indicated the Vitamin D level in 8 fluid ounces (fl. oz.), was 5 mcg and Calcium was 591 mg. A review of Resident 7's Multi-vitamin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 22 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Supplement Facts indicated the Vitamin D was 450 IU. However, for calcium there were two values: energy support was 42 mg and bone support 759. In a phone interview with the Director of Nurses (DON) on June 11, 2019, at 1 p.m., stated she did not know what these two classifications were and was not sure of the actual content of the Calcium. If Resident 7 only consumed 50% of her meals she received vitamin D of 5 mcg per day. Resident 7 consumed 100% of her twice daily 4 oz shakes (as indicated in January 2019, and February 2019, Medication Administration Records-MAR) which 5 mcg. Resident 7's multivitamin contained 450 IU which equals 11.25 mcg. (450 IU x 0.025 because 1 IU = 0.025 mcg). According to the facility's Menu Nutrient Analysis chart Resident 7's received the daily required amount of Vitamin D, of 10.1 micrograms (mcg) (reference range for osteoporosis requirement is 20 mcg). Resident 7's Calcium calculation indicates the resident consumes 50% of meals and the facility's Menu Nutrient Analysis chart indicates the resident would have 650 mg calcium per day and 591 mg of calcium provided with the multivitamin. A review of Resident 7's Nutrition Notes made by the Dietary Director (DD) from September 2018, through June 2019, did not indicate daily vitamin or mineral requirements for Resident 7, to address the resident's osteoporosis. There was no calculation for vitamin D or calcium as a part of Resident 7's Care Plans related to Osteoporosis. Estimating that Resident 7 eats at least 50% of her meals and drinks 100% of her nutrition shakes and takes her multivitamin daily, Resident 7 appears to be receiving the daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 23 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recommendation of Calcium and Vitamin D 3. There is no baseline Vitamin D lab (laboratory) to evaluate if Resident 7 is absorbing the vitamin D provided to the resident through her meals, supplements or the multi-vitamin. During an interview with Resident 7 on June 4, 2019, at 8:42 a.m., Resident 7 was alert and oriented. Resident 7 stated she did not remember breaking her hip. Resident 7 stated, "Oh, that's my leg and put her hand to her right side. During an interview with the Assistant Director of Nurses (ADON) and concurrent record review on June 6, 2019 at 9:03 a.m., she presented a blank Osteoporosis/Osteopenia Prevention/Management Physician's Order Sheet that was part of the Fracture Prevention Policy and Procedure. The policy had no initiation date. The ADON stated the implementation date was May 23, 2019. A review of this form indicated the following: ( ) Vitamin D 25 OH (Hydroxy) level ( ) Calcium level ( ) Repeat Vitamin D 25 OH level every 6 months thereafter ( ) Repeat Calcium Level every 6 months thereafter ( ) Oscal + Vitamin D 500 milligrams/400 units ( ) Every Day ( ) Twice a day ( ) Calcium Carbonate 500 milligrams ( ) Every Day ( ) Twice a day ( ) Vitamin D 3 by mouth every day ( ) 1000 International Units (IU) , ( ) 2000 IU, ( ) 4000 IU, ( ) 5000 IU ( ) Vitamin D 2 50, 000 IU by mouth per week for ___weeks. The ADON stated the Osteoporosis/Osteopenia Prevention/Management Physician's Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 24 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Sheet is presented to a resident's physician and the physician would indicate which items he wanted to choose, based on a resident's clinical status. The ADON stated the policy for the Physician's Form for osteoporosis/osteopenia prevention/management was started in use by staff on May 23, 2019. A review of the Fracture Prevention Policy and Procedure, initiated on May 23, 2019, indicated that for new admission residents, with an osteoporosis diagnosis, the resident's physician will order baseline Vitamin D 25 OH and Calcium level and every six months hereafter. The policy did not include the reference range (normal lab values) for either Vitamin D 25 OH or Calcium. The policy did not specify whether the Calcium level to be drawn was a total Calcium (used to measure the total amount of calcium in your blood) or ionized Calcium (is calcium in the blood that is not attached to proteins). During an interview with Resident 7's primary physician, (MD 1) on June 6, 2019, at 11:05 a.m., he stated he thought Resident 7 was getting enough vitamin D in her diet, but did not specify how he made that determination. When asked why Vitamin D 3 was not prescribed until after the fracture, he stated Resident 7's osteoporosis was not on the resident's problem list. MD 1 stated he does not check a vitamin D 3 level until after a resident has a fracture. MD 1 stated he does not usually order a vitamin D 3 level before starting the medication or after a resident has been taking the medication. MD 1 stated there never was a bone density test (a test conducted to determine how strong the bones are and if they are not strong, then supplements such as vitamin D or calcium can be prescribed to make them stronger) conducted for Resident 7. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 25 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the physician progress notes indicated there was no evidence of an evaluation from the physician to indicate whether the resident is a candidate for taking medications for treating osteoporosis based on severity of bone loss. In an interview the DON was unable to produce physician progress notes that indicated an evaluation had been done by the physician. During an interview with the Medical Records Director (MRD) on June 6, 2019, at 12:00 p.m., he stated he had looked in Resident 7's records to see if the resident had received a vitamin D 3 supplement before being started on it on February 21, 2019. The MRD stated there was no record of Resident 7 receiving a vitamin D 3 supplement before February 21, 2019. During an interview on June 7, 2019 at 2:22 p.m., the Dietary Director (DD) stated for a resident with osteoporosis, she looks to make sure there is an adequate calcium intake from meals, including milk and other dairy products including the mineral content of a resident's nutrition shake. During an interview on June 11, 2019 at 1:35 p.m., the DD stated she did not make the recommendation for Resident 7 to be placed on the Vitamin D 2000 IU daily. The DD stated if she made any recommendations about supplementation for the resident's osteoporosis, the recommendations would be in her notes. A review of the facility's policy and procedure titled, "Osteoporosis - Clinical Protocol, reviewed January 17, 2019, which was in effect at the time of Resident 7's fall on February 18, 2019, indicated: 1. The physician will order calcium and vitamin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 26 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE D supplementation as appropriate and if not contraindicated. Calcium and vitamin D supplementation total daily amounts (including dietary intake) should approximate 1200-1500 mg/day of calcium and 800-1000 IU/day of vitamin D. 2. The physician will evaluate whether the resident is a candidate for taking medications for treating osteoporosis based on severity of bone loss. A review of the facility's policy and procedure titled, "Care Plans - Comprehensive," reviewed January 17, 2019, indicated the care plan should reflect treatment goals, timetables and objectives in measurable outcomes. The policy indicated areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments [CAAs]) before interventions are added to the care plan.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 07/22/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 27 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop or revise an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of eight sampled residents (Residents 128 and 17) by: 1. Failing to revise the care plan after the oxygen order was changed for Residents 128. This deficient practice had the potential to result in a delay of or lack in provision of sufficient oxygen. 2. Failing to revise the behavioral care plans when behavioral data indicated that the care planned interventions were not meeting the resident's goals for behavior reduction for Resident 17. This deficient practice caused Resident 17 to continue to receive care interventions that were not adequate or optimized to address behaviors related to her medical conditions increasing the risk of a negative impact to her health and well-being. Findings: a. A review of Resident 128's Admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 28 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Record indicated the resident was originally admitted to the facility on January 23, 2017, and readmitted on March 16, 2019, with diagnoses of, but not limited to, muscle weakness and seizure disorder (a medical condition that is characterized by episodes of uncontrolled electrical activity in the brain). A review of Resident 128's Minimum Data Set (MDS- a standardized assessment and screening tool) dated May 22, 2019, indicated that Resident 128's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated the resident is totally dependent on staff for locomotion off and on unit, and toilet use. A review of the Physician Orders dated March 16, 2019, indicated to provide Resident 128 oxygen (O2) at 2 liters per minute (L/m) via nasal cannula (a thin tube) continuously for respiratory failure. A review of the Physician Orders dated April 4, 2019, indicated Resident 128's oxygen (O2) was increased to provide the resident oxygen at 4 L/m via nasal cannula continuously for respiratory failure. A review of the Oxygen Therapy Care Plan initiated on March 16, 2019, indicated the resident is at risk for respiratory distress related to cough and irregular respiration. The intervention included to administer oxygen as ordered and monitor oxygen saturation as needed. Another care plan dated May 22, 2019, indicated Resident 128 has a potential for breathing pattern alteration related to acute respiratory failure. The approaches included to elevate head of bed and assist to assume FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 29 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE position of comfort if needed. Supplemental oxygen as ordered. Monitor or observe for signs and symptoms of respiratory distress such as nasal flaring, increased congestion, neck vein distention, productive cough, use of axillary muscles for breathing. Report to the physician as noted any significant abnormalities/changes in condition. The care plan was not updated when the order indicated to increase oxygen amount from 2 L/m to 4 L/m via N/C continuously on April 4, 2019. On June 10, 2019, at 2:55 p.m., at a concurrent record review and interview, Registered Nurse 1 (RN 1) stated she was unable to provide documented evidence the care plan for increased oxygen amount on April 4, 2019, was revised or developed. RN 1 stated that even if the previous care plan did not specify the amount of oxygen supply in interventions, the licensed nurses should have entered the date of change of the order. A review of the facility's policy and procedure dated December 2000, titled, "Care PlansComprehensive," indicated the facility's care planning/Interdisciplinary Team (IDT), in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The care planning/Interdisciplinary team is responsible for the review, updating and revision of care plans: when there has been a significant change in the resident's condition; when the desired outcome is not met. b. On 06/06/19, at 08:46 AM, during a record review, Resident 17's clinical (medical) record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 30 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that she was initially admitted to the facility on 8/30/18, with diagnoses including, but not limited to: major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) A review of Resident 17's physician order dated 10/22/18, indicated that she was prescribed sertraline (a medication used to treat MDD) 50 milligrams (mg) every day and 100 mg every night at bedtime for depression manifested by "recurrent episode of tearfulness." A review of Resident 17's physician order dated 10/22/18, indicated that she was prescribed buspirone (a medication used to treat anxiety disorder) 10 mg twice daily for anxiety manifested by "repetitive utterance of 'Oh I see' without apparent reason." A review of Resident 17's care plan titled "AntiAnxiety Drug Therapy" dated 10/22/18, indicated that the Interdisciplinary Team (IDT a group of individuals from different medical backgrounds tasked with creating and revising plans of care for residents living in skilled nursing facilities) had created the goal of "episodes of anxiety will be limited to: 0-1 per week" for the use of buspirone to control Resident 17's "repetitive utterance of 'Oh I see' without apparent reason." A review of Resident 17's "Annual Psychotherapeutic Drug Summary Sheet/Monitoring" for buspirone indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 31 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in October 2018, the resident had 18 documented episodes of "repetitive utterance of 'Oh I see' without apparent reason." There were 47 episodes in November 2018, 27 in December 2018, 50 in January 2019, 85 in February 2019, 69 in March 2019 and 113 in April 2019. A review of the "Psychotropic Med Review" document for buspirone indicated that Resident 17's physicians specifically reviewed the use of buspirone to treat anxiety manifested by "repetitive utterance of 'Oh I see' without apparent reason" on 1/10/19 and 4/10/19 making the recommendation on each date to continue buspirone therapy without any changes. A review of the clinical record indicated that there was no evidence that the IDT revised the anti-anxiety care plan when it was reviewed in January 2019 or March 2019. A review of Resident 17's care plan titled "AntiDepressant Drug Therapy" dated 8/30/18, indicated that the IDT created the goal of "will have less than two episodes of "recurrent episode of tearfulness" per week for the next three months." A review of Resident 17's "Annual Psychotherapeutic Drug Summary Sheet/Monitoring" for sertraline indicated that in September 2019, the resident had 56 documented episodes of "recurrent episode of tearfulness," 75 in October 2018, 33 in November 2018, 16 in December 2018, 42 in January 2019, 79 in February 2019, 67 in March 2019, and 100 in April 2019. A review of the "Psychotropic Med Review" document for sertraline indicated that Resident 17's physicians specifically reviewed the use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 32 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sertraline to treat depression manifested by "recurrent episode of tearfulness" on 1/10/19 and 4/10/19, making the recommendation on each date to continue sertraline therapy without any changes. A review of the clinical record indicated that there was no evidence that the IDT revised the anti-depressant care plan when it was reviewed in November 2018, December 2018, or March 2019. On 06/06/19, at 10:31 AM, during an interview the Director of Nursing (DON) stated that Resident 17's care plans for anxiety and depression have not been revised since their creation even though the behaviors are increasing. The DON stated that she would expect the medications or doses to be reevaluated and the care plans to be revised given that the target behaviors are trending upward and exceeding the clinical goals set by the IDT. On 06/06/19, at 10:49 AM, during an interview, Minimum Data Set Nurse 3 (MDS Nurse 3) stated that she is responsible for developing and revising the resident's care plans. MDS Nurse 3 stated that she failed to revise Resident 17's care plans even though she looked at the behavioral data and acknowledged that there was an upward trend of observed behaviors for both anxiety and depression. The MDS Nurse 3 stated that the care plans need to be revised because the use of sertraline and buspirone do not seem to be effective at treating their respective conditions. MDS Nurse 3 stated that the care planned interventions of using buspirone and sertraline to control their respective target behaviors are "absolutely not" meeting the clinical goals set by the IDT and stated that she failed to consider revising the care plan on each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 33 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE occasion it was reviewed. The MDS Nurse 3 stated that she will revise the care plans during the upcoming IDT meeting in June 2019. A review of the facility's policy titled "Care Plans - Comprehensive" revised December 2010, indicated that "assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change" and "The Care Planning/Interdisciplinary Team is responsible for the review, updating and revision of care plans: when the desired outcome is not met."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 07/22/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 sampled residents (Resident 36, 133) reviewed for accidents by: 1. Failing to ensure a resident who had histories of getting out of bed and wheelchair unassisted was fully assessed and identified through the facility Incident Reports the probable cause of the resident's falls, in order to develop interventions likely to minimize the chance for additional falls for Resident 36. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 34 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These deficient practices resulted in Resident 36, having five falls within three months that included a fall on May 15, 2019, where the resident sustained a right femoral (thigh bone) neck (the ball-and-socket, hip joint) fracture (broken bone), that required an ORIF, (open reduction and internal fixation, a type of surgery used to fix broken bones) at a general acute care hospital (GACH). 2. Failing to ensure that a resident was deemed safe to smoke as per the facility's Resident Smoking Assessment by not having a physician's order indicating the resident can smoke for Resident 133. This deficient practice had the potential to create an unsafe environment. Findings: a. A review of Resident 36's Admission Record indicated the resident was originally admitted to the facility on September 11, 2018, and readmitted to the facility on May 18, 2019, with diagnoses that included, cerebrovascular accident (CVA - a stroke), hemiplegia (partial paralysis or weakness affecting one side on one side of the body), retention of urine (difficulty urinating and completely emptying the bladder), difficulty walking, history of falling, and aftercare (immediate care after the release from a hospital stay) following joint surgery (a surgical replacement procedure), right femoral (the long thigh bone) neck (the ball-and-socket hip joint) fracture (a broken bone). A review of Resident 36's Fall Risk Assessment dated December 4, 2018, indicated the resident was alert, had a history of three (3) or more falls and a chair bound. Resident 36's Fall Risk Assessment Form, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 35 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 36, had a fall risk score of 14. The Fall Risk Assessment indicated that a score of 14 or above represents a high risk for falls. A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated December 19, 2018, indicated Resident 36's Brief Interview for Mental Status (BIMS) score was 14. A BIMS score of 14 indicates the resident is cognitively (mental processes of thinking and understanding) intact for daily living decisions. Resident 36 required extensive assistance by staff with activities of daily living (ADLs) such as transfers, toilet use, and walking in his room with one person physical assistance to provide weight-bearing, support. A review of Resident 36's Quarterly Minimum Data Set (MDS) dated March 19, 2019, indicated Resident 36 had a decline in his cognition from December 19, when he had a BIMS score of 14, to March 19, 2019, when his Brief Interview for Mental Status (BIMS) score was 9. A BIMS score of 9 indicates the resident has moderately impaired cognition for daily living decisions. The MDS indicated Resident 36 continued to require extensive assistance on staff with activities of daily living (ADLs) such as transfers, toilet use, walking in his room. The MDS indicated Resident 36 was not steady, for moving from seated to standing position, walking, and turning around. The MDS indicated the resident had functional limitation in range of motion with impairment on one side of his upper extremities (shoulder, elbow, wrist or hand), and normally used a walker and wheelchair. A review of the facility's Incident Reports indicated Resident 36 had the following fall incidents: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 36 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. On February 10, 2019, at 5:10 p.m., Resident 36, had a fall to the floor (first fall). Resident 36 was found by the certified nursing assistant lying on his back on the floor, between the wheelchair and bed. Resident 36 stated, "I was trying to sit in my chair." Upon assessment, Resident 36 had a bump to the left side of his head. Injuries: Bump on left side of head 3 centimeters (cm's) in length and 2 cm's width. Care planning or Interdisciplinary Team (IDT- a group of health care professionals from diverse fields) was not documented. MD (medical doctor) Notified: MD notified at 5:30 p.m., and ordered that Resident 36, was transferred to the GACH ER (emergency room)Department for evaluation of bump to left side of his head. The February 10, 2019, incident report did not indicate how the nursing staff would be alerted when the resident was attempting to stand from his wheelchair or specify the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. 2. On February 17, 2019, at 10 p.m., indicated Resident 36, was found on the floor, (second fall) on his left side. The February 17, 2019, incident report did not address the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. 3. On February 27, 2019, at 2 p.m., Resident 36 had an unwitnessed fall to the floor, (third fall) on his way to the bathroom. Resident 36 complained of right hip pain at a pain rating of 4 of 10, (on a pain rating level of zero being no pain, and 10 being the worst possible pain). Pain medication given. The incident report did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 37 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not address provision of routine toileting, or ongoing supervision of the resident to decrease the resident's attempts to go to the bathroom without assistance. 4. On March 12, 2019, at 4:55 p.m., Resident 36 had an unwitnessed fall to the floor (fourth fall). The resident's account of the fall indicated he went to the bathroom and his feet felt weak so he sat down on the floor. Nursing Interventions indicated to provide a toileting schedule time for 30 days. The incident report did not include the use of a wheelchair alarm as a possible fall prevention intervention to remind the resident to call for assistance, and or to alert the staff when the resident was attempting to stand or walk without assistance, and did not address ongoing supervision of the resident to prevent falls. 5. On May 15, 2019, at around 8:45 a.m., a licensed nurse (Licensed Nurse 10) heard Resident 36 calling for help inside his room. Resident 36 was found at the foot of his bed (5th fall). Resident 36 stated he wanted to go to the bathroom, and stood up from the wheelchair and lost his balance and fell to the floor. A review of Resident 36's Post Fall Assessment/Rehab Team, dated May 15, 2019, at 8:45 a.m., indicated the resident has a change in functional status unable to do range of motion (ROM-joint movement) on bilateral (both) lower extremities (legs) due to pain. Resident 36 complained of pain in both hips, knee, and thigh. Pain medication given. The documentation indicated Resident 36 will be transferred to GACH emergency room (ER) per physician order. A review of Resident 36's Diagnostic Radiology result, dated May 15, 2019, at 12:23 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 38 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated mildly impacted (the ends of the fractured bone are wedged together) fracture involving the right femoral (thigh bone) neck (socket joint of the hip) with minimal displacement (out of place): A review of Resident 36's physician order dated May 15, 2019, indicated to send the resident to a GACH for further evaluation of a right hip fracture. A review of Resident 36's, GACH Orders and Discharge Summary dated May 17, 2019, at 2:15 p.m., indicated Resident 36 underwent an operation/procedure: Hip pinning cannulated (to insert) screws, percutaneous (through the skin, to fix the fracture). Resident 36 was admitted for physical therapy evaluation, pain control and wound evaluation. Resident 36 progressed slowly with physical therapy and required further treatments. After Resident 36's pain was controlled with oral (by mouth) pain medications, the resident was medically stable, and ready to be transferred back to the skilled nursing facility (SNF) for continued rehabilitation. A review of Resident 36's Care Area Assessment (CAA) dated March 19, 2019, triggered for fall. The CAA was not completed as follows: there was no analysis of the assessment findings to include causes and contributing factors for each of the resident's falls. A review of Resident 36's care plan dated December 7, 2018, titled Fall Risk, indicated the resident required extensive assistance from staff with walking. There were no revisions made to the care plan after the resident's falls of February 10, 17, 27, 2019, but was updated on March 12, 2019, and March 27, 2019, after the resident's fifth fall. The care plan goal: "Will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 39 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reduce/minimize risk of injury/potential injuries from falls time 90 days." related to partial loss of ability to balance, moving from seated to standing position, unsteadiness on feet. The care plan Approaches/Interventions included the following: -Encourage resident to move to a room closer to the nurses' station -Toileting schedule for 30 days -Nurses would walk the resident ad/lib (as desired) with or without an assistive device -One person assist with transfers -One person assist with walking The care plan did not include how the nursing staff would be alerted when Resident 36 was attempting to stand or walk from a wheelchair, or specify the need for ongoing supervision, in order to provide necessary physical assistance to reduce/minimize risk of injury/potential injuries from falls. The care plan did not include the need for a wheelchair pad alarm and or not specify when, or how, the resident would be assisted with walking, or with toileting to ensure the resident was safe during walking and toileting activities. A review of Resident 36 physician order dated indicated April 4, 2019, bed pad alarm while bed as reminder to resident to ask for assistance. On June 5, 2019, at 10:52 a.m., during an interview and concurrent record review of Resident 36's care plan, the Director of Nursing (DON) was unable to provide documentation that the facility analyzed the cause of Resident 36's five falls within three months and identified measure to prevent Resident 36 from falls. A review of the facility's undated policy and procedures titled, "Fall/Accident Mitigation and Intervention," indicated under Policy: It is the policy of this facility to minimize the risk of falls FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 40 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or accidents, and minimize the risk of serious injury associated with falls or accidents. Procedure: - Residents at risk for falls shall have a care plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. - After proper assessment of the resident, notification of the appropriate persons, and after the resident is stable, the facility staff member in charge will complete a report and forward to management as per the facility policy. - The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrence of a fall or other event. A review of the facility's policy and procedures titled, Fall Prevention, dated August 2013, indicated to reduce the number of fall incident and to help minimize the risk of injuries from falls. The policy indicated, a fall prevention program will be developed for each patient that will provide patient care staff with creative functional strategies to minimize falls. - The Falls/Risk Committee members meet to analyze interdisciplinary data related to the fall incident/injury and recommend an appropriate intervention to minimize the patient's risk for fall or injury. - The MDS/Care planning Interdisciplinary Team updates the resident's plan of care to include the additional recommendation(s) made by the Falls/Risk committee. b. A review of Resident 133's Face Sheet (admission record) indicated the resident was admitted to the facility on May 16, 2017, and with a readmission on April 22, 2019. The resident's diagnoses included, but was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 41 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to, sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), hypertension (high blood pressure), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), atrial fibrillation (irregular rapid heart rate). A review of Resident 133's Minimum Data Set (MDS- an assessment and care screening tool) dated May 5, 2019, indicated the resident has a Brief Interview for Mental Status (BIMS- a screening tool to determine cognitive impairment) score of 15 (a score of 13-15 indicates the resident has intact cognition) and has the ability to make self-understood and the ability to understand others. A review of Resident 133's "Resident Smoking Assessment Form" dated April 19, 2018, indicated that Resident 133 does not have a physician's order allowing him to smoke. The form indicated, "Note: if a resident smokes they must be supervised and the physician's order must indicate the resident is deemed competent, is able to understand and follow the facility's smoking policy, and that the physician feels the resident is safe to smoke." During a concurrent interview and record review on June 6, 2019, at 3:15 p.m., Social Service 2 (SS2) stated she completed the Resident Smoking Assessment Form and confirmed that Resident 133 does not have a physician's order indicating the resident can smoke per the facility policy. SSD 2 also stated that she had not marked the outcome of the assessment indicating if the resident is considered a safe smoker or unsafe smoker. During a concurrent interview and record review on June 6, 2019, at 4:17 p.m., the Director of Nursing (DON) stated that according FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 42 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to the Resident Smoking Assessment Form, residents who wish to smoke at the facility would need a physician's order indicating that it is safe for the resident to smoke. The DON confirmed that Resident 133 does not have a physician's order indicating that the resident can smoke per the facility's policy.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 07/22/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 43 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to assess, and ensure that the nursing staff, adhered to infection control practices, for a resident with indwelling urinary catheter, for one of one sampled resident (Resident 144) reviewed for urinary tract infection (UTI-an infection in any part of your urinary system.) This deficient practice had the potential to result in urinary tract infections for Resident 144. Findings: On June 3, 2019, at 10:09 a.m., Resident 144, was observed in bed during a wound care observation, while Certified Nursing Assistant 13 (C. N. A 13) positioned the resident on his right side. The treatment nurse, Licensed Vocational Nurse 12 (L.V.N 12), removed Resident 144's soiled sacrococcyx (low back) dressing (bandage), while Resident 144's urinary catheter drainage bag and urinary drainage tubing was observed at the foot of his bed, with 200 milliliters (ml) of medium amber colored urine. On June 3, 2019, at 10:10 a.m., during an interview, when asked about Resident 144's urinary catheter drainage bag and urinary drainage tubing, CNA 13 stated, "I placed Resident 144's urinary catheter on his bed." On June 3, 2019, at 10:11 a.m., during in interview, LVN 12 stated, "Resident 144's drainage bag should not be elevated to the level of the resident's bladder, because of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 44 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE potential for a UTI (Urinary Tract Infection)." On June 3, 2019, at 10:21 a.m., during an interview the Director of Nursing (DON), stated it is not the facility policy or procedure to place the residents' urinary catheter's drainage bag at the level of the bladder. A review of Resident 144's Admission record (Face sheet), indicated Resident 144 was originally admitted to the facility on February 15, 2019, with diagnoses that included, muscle weakness, benign prostatic hyperpiesia (BPHan enlarged prostate gland), and bacteremia (sepsis, severe sepsis, and septic shock-the body's overwhelming and life-threatening response to infection). A review of Resident 144's Physician's order dated April 27, 2019, indicated to keep the urinary collection bag below level of the bladder at all times, every shift, Foley (a urinary catheter) Catheter #16 (size of catheter) French (a type of catheter) /10 centimeters (cc) (the size of the internal bulb/balloon that anchors the urinary catheter in place) to bedside drainage change every month and when (PRN) pulled out or clogged, Foley (urinary) catheter care daily, Check Foley catheter for urine consistency, color, clear/yellow, cloudy/bloody/odor and pus every shift. A review of Resident 144's Annual Minimum Data Set (MDS-an assessment and care planning tool), dated May 24, 2019, indicated Resident 144 had a BIMS (Brief Interview for Mental Status) score of 15. A BIMS score of 15 indicates the resident is cognitively intact. Resident 144 was dependent on staff, with activities of daily living, such as personal hygiene and dressing. Section H: Bladder and Bowel, indicated Resident 144 was assessed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 45 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with an indwelling catheter, and was always incontinent. A review of Resident 144's undated Care Plan titled "Bladder Elimination-Appliance Use: Related to Alteration in Urinary Elimination Secondary to use of Indwelling Catheter: Manifested by Foley (urinary) catheter and BPH," indicated Resident 144 was at risk for UTI due to catheter use. The Approaches/Intervention included the following: -Maintain proper alignment of catheter to promote proper drainage -Keep drainage bag off the floor every shift -Keep (urinary) collection bag below the level of the bladder at all times, every shift A review of Resident 144's care plan goal dated August 2019, indicated the resident's bladder will be adequately emptied without any complications, i.e. bladder distention or pain daily for the next 90 days and reduce the risk of infection daily times 90 days. A review of the facility's policy and procedure titled, "Catheter Drainage Bag," dated January 2012, indicated Procedure: Standard Drainage Bag, keep the catheter and drainage bag tubing free of kinks, the resident should not be lying on the tubing, the drainage bag tubing should not be placed or coiled, to facilitate straight drainage, and keep the drainage bag below the level of the patient/resident's bladder.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 07/22/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 46 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered by the physician for one of one sampled resident (Resident 128). This deficient practice placed Resident 128 at risk of having oxygen toxicity (a condition resulting from the harmful effects of breathing molecular oxygen at increased partial pressures. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs, and eyes). Findings: A review of Resident 128's Admission Record indicated the resident was originally admitted to the facility on January 23, 2017, and readmitted on March 16, 2019, with diagnoses of, but not limited to, muscle weakness and respiratory failure. A review of Resident 128's Minimum Data Set (MDS- a standardized assessment and screening tool) dated May 22, 2019, indicated that Resident 128's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated the resident is totally dependent on staff for locomotion off and on unit, and toilet use. On June 5, 2019, at 2:45 p.m., Resident 128 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 47 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was observed sleeping in bed. The resident was receiving oxygen at five liters per minute (5 L/m) via nasal cannula (N/C-a device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help. This device consists of a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), attached to an oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to a patient/resident in need of supplemental oxygen). A review of Resident 128's physician's order dated April 4, 2019, indicated to administer oxygen at 4 L/m via N/C continuously for respiratory failure. At a concurrent observation and interview Licensed Vocational Nurse 1 (LVN 1), stated that Resident 128 was supposed to receive oxygen at two to three liters per minute. LVN 1 immediately lowered the resident's oxygen amount to two liters per minute (2 L/m). A review of Resident 128's Medication Administration Record indicated the resident's oxygen saturation (the amount of oxygen carried in the body) on June 5, 2019, during 7 a.m., to 3:30 p.m., shift was 96 percent (%). The normal adult pulse oximeter (a device used to monitor oxygen saturation) readings usually range from 95 % to 100 %. A review of Resident 128's care plan initiated on March 16, 2019, indicated the resident is at risk for respiratory distress related to cough and irregular respiration. The intervention included to administer oxygen as ordered and monitor oxygen saturation as needed. Another care plan dated May 22, 2019, indicated Resident 128 has a potential for breathing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 48 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pattern alteration related to acute respiratory failure. The approaches or interventions included to elevate head of bed and assist to assume position of comfort if needed. Supplemental oxygen as ordered. Monitor or observe for signs and symptoms of respiratory distress such as nasal flaring, increased congestion, neck vein distention, productive cough, use of axillary muscles for breathing. Report to the physician as noted any significant abnormalities/changes in condition. A review of the facility's policy and procedure dated October 2010, titled, "Oxygen Administration," indicated staff to verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration.

F726 SS=D Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 07/22/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 49 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a newly hired nurse adequate training and orientation to the facility's policies and procedures to ensure competency in administering medications prior to allowing the nurse to work unsupervised. This deficient practice caused one of three residents (Resident 58) observed for medication administration, to receive 12 doses of potassium chloride (a medication used to supplement potassium levels) in a manner that could have caused symptoms of stomach irritation including, but not limited to: nausea, vomiting, or diarrhea. Findings: A review of Resident 58's clinical (medical) record indicated that the resident was originally admitted to the facility on 4/9/18, with diagnoses including, but not limited to: dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure.) On 06/05/19, at 08:02 AM, during an interview, Licensed Vocational Nurse (LVN 2) stated that she has been working as an LVN for over 20 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 50 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE years, but has only been with this facility for around two weeks. On 06/05/19, at 08:08 AM, LVN 2 was observed preparing the following medications for Resident 58: 1. Docusate sodium 100 milligrams (mg) tablet (a stool softener) 2. Gabapentin 300 mg capsule (a medication used to treat nerve pain) 3. Memantine ER (extended release) 28 mg (a long acting form of a medication used to treat memory problems) 4. Potassium Chloride ER 20 milliequivalents (mEq) tablet (a potassium supplement) 5. Furosemide 20 mg tablet (a medication used to treat swelling) 6. Digoxin 0.125 mg tablet (a medication used to treat heart conditions) 7. Metoprolol tartrate 25 mg tablet (a medication used to treat high blood pressure) 8. Montelukast 10 mg tablet (a medication used to treat allergies) 9. Paroxetine 10 mg tablet (a medication used to treat mental illness) 10. Vitamin D 2000 International Units (IU) tablet (a vitamin supplement) 11. Multivitamin with minerals tablet (a vitamin supplement) 12. Ferrous sulfate 325 mg tablet (an iron supplement) 13. Polyethylene glycol powder (a laxative) During a concurrent interview, LVN 2 stated that Resident 58 needed to have her medications crushed because she had difficulty swallowing, but that she cannot crush the memantine ER or the ferrous sulfate because "those aren't supposed to be crushed." LVN 2 was observed crushing all of Resident 58's other tablet medications (except for the memantine, ferrous sulfate, and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 51 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE polyethylene glycol powder) and opening the capsules and mixing all of their contents together into one dosage cup. LVN 2 stated that she mixes all of Resident 58's medications together with applesauce and spoon feeds the mixture to her by mouth. LVN 2 then stated that the dosage of polyethylene glycol powder was "eight ounces" and was observed filling a oneounce medication cup full of powder. The LVN stated this was the correct dose and proceeded to mix the powder into a small cup of juice. LVN 2 entered the resident's room an intended to administer the above medications as described to the resident, but was interrupted for resident safety and asked to recheck the resident's orders. On 06/05/19, at 08:35 AM, during an interview, LVN 2 stated that she crushed Resident 58's potassium chloride tablets but now realizes, because she was stopped from administering the medications that they are not supposed to be crushed. LVN 2 stated that she has been crushing the potassium chloride tablets and administering them to Resident 58 for "as long as she can remember." LVN 2 stated that giving potassium chloride in this manner may cause stomach irritation to the resident. During a concurrent interview, LVN 2 stated that she mixed eight ounces of Resident 58's polyethylene glycol powder using a dosage cup and demonstrated that she was correct by pointing to the side of the medication cup that read "eight drams (a unit of measure for volume roughly equal to one-eighth of an ounce)." When asked to recheck the order, LVN 2 stated that the dose of polyethylene glycol powder should have been 17 grams mixed in eight ounces of water or juice. LVN 2 stated that she prepared the wrong dose of the polyethylene as she did not use the cap from the bottle to measure 17 grams, as required by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 52 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the product's manufacturer and could not say how many grams were in the dosage cup. LVN 2 also stated that she "doesn't know" what volume of juice she used to dissolve the powder. LVN 2 was again asked to recheck the physician's order. LVN 2 stated that the 17-gram dose should be dissolve into eight ounces of water or juice. LVN 2 stated she has no way to measure out accurately eight ounces as the cups used for juice do not have markings to determine what volume of liquid they contain. LVN 2 was then asked to ask her supervisor what the correct procedure should be to ensure accuracy of the dose. During a concurrent interview, the Assistant Director of Nursing (ADON) stated that potassium chloride tablets should never be crushed and the polyethylene glycol powder should be measured using the cap from the bottle, otherwise there's no way to ensure that Resident 58 receives the 17-gram dose. The ADON stated that the juice needs to be measured using the dosage cups calibrated to one ounce to measure out eight ounces. LVN 2 was observed using a dosage cup to fill one of the plastic juice cups whose total volume came out to be around four ounces. The ADON stated that Resident 58's powder should be split between two juice cups to measure out the full eight ounces specified in the physician's order. The LVN 2 stated that she not only measured the wrong dose of the polyethylene glycol powder, but also the wrong volume of liquid in which to mix it. LVN 2 stated that she would have given a dose of polyethylene glycol powder, that was lower than the amount specified in Resident 58's physician order which could have led to the resident developing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 53 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE constipation. On 06/05/19, at 09:02 AM, during an interview, the ADON stated that the nurse consultants from the contracted pharmacy are responsible for training new employees on the correct medication administration procedures and stated that the nurse consultant has observed LVN 2 perform medication administration since she was hired. On 06/05/19 at 09:32 AM, the ADON provided a handwritten document indicating that LVN 2's date of hire was 5/6/19, and she has passed medications (including potassium chloride) to Resident 58 on 5/13, 5/14, 5/15, 5/22, 5/23, 5/24, 5/26, 5/27, 5/28, 6/3, 6/4, and 6/5 (12 doses). A review of Resident 58's medication administration record (MAR - a record of each medication given to a resident) from May and June of 2019, confirmed the information provided by the ADON indicating that LVN 2 had crushed and given a total of 12 doses of potassium chloride to Resident 58. On 06/05/19, at 09:40 AM, during an interview, the ADON stated that they don't have any training records for medication administration for LVN 2, but have requested it from the contracted pharmacy. The ADON stated that they have removed her from administering medications this morning and sent her home. On 06/05/19, at 09:55 AM, during a review of Resident 58's clinical record, no physician order or other evidence that the resident's medications needed to be crushed prior to administration could be found. A review of LVN 2's training record indicated that the contracted pharmacy had observed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 54 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 2 administering medications on 5/28/19, and had marked her technique of administering bulk laxatives (such as polyethylene glycol powder) and crushing only appropriate medications as "correct." A review of the facility's policy titled "Orientation Program" revised September 2003, indicated that "All newly hired personnel must attend an orientation program within their first five (5) days of employment" to include "an introduction to resident care procedures, which includes a review of the facility's: policies and procedures." On 06/05/19, at 02:44 PM, during an interview the ADON stated that LVN 2 was not given an orientation to the policies and procedures in the facility within five days of employment and could not produce any records to indicate that she had received any training at all, other than one observation from the contracted pharmacy on 5/28/19, since her date of hire on 5/6/19. The ADON stated that she agreed that facility failed to provide LVN 2 with adequate training or oversight, especially regarding her technique preparing and administering medications, before being allowed to provide direct care to residents unsupervised.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 07/22/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 55 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based observation, interview, and record review, the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) for six of six residents (Resident 117, 100, 7, 75, 131, 27), sampled for review of controlled substances, stored in one of three inspected medication carts (Medication Cart #4). The deficient practice of failing to accurately account for the use of controlled substances increases the risk that medications may not be available for the facility's residents when needed and also puts the facility at increased risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 56 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 06/03/19, at 11:50 AM, during an observation of Medication Cart #4, the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 117's Narcotic and Hypnotic Record for tramadol (a medication used to treat moderate pain) 50 milligram (mg) indicated that there were 38 doses left, however, the medication card only contained 36 doses. 2. Resident 100's Narcotic and Hypnotic Record for oxandrolone (a male hormone replacement therapy) 2.5 mg indicated there were three doses left, however, the medication card only contained two doses. 3. Resident 7's Narcotic and Hypnotic Record for hydrocodone/acetaminophen (a medication used to treat moderate pain) 5/325 mg indicated there were three doses left, however, the medication card only contained two doses. 4. Resident 75's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness) 0.5 mg indicated there were six doses left, however, the medication card only contained five doses. 5. Resident 131's Narcotic and Hypnotic Record for Lyrica (a medication used to treat nerve pain) 50 mg indicated there were 13 doses left, however, the medication card only contained 12 doses. 6. Resident 27's Narcotic and Hypnotic Record for tramadol 50 mg indicated that there were 23 doses left, however, the medication card only contained 22 doses. On 06/03/19 at 12:05 PM, during an interview, Licensed Vocational Nurse 3 (LVN 3) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 57 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that she had administered all of the missing doses identified from the Narcotic and Hypnotic Record reconciliation that morning during her 9:00 AM medication administration. LVN 3 stated that she failed to sign for the six missing doses because she "forgot this time." LVN 3 stated that she understands that the facility's policy is to sign the Narcotic and Hypnotic Record immediately after the dose of any controlled medication is given to a resident. During a concurrent interview, the Assistant Director of Nursing (ADON) stated that all of the missing doses discovered in Medication Cart #4 were given during that morning's medication administration and that LVN 3 had administered the missing doses, but failed to sign for each of the doses she administered in violation of the facility's policy. A review of the facility's undated policy titled "Medication Administration" indicated that "The person administering the medication is to initial the resident's medication sheet in the space under the appropriate date and time for that particular dose administered" and "Documentation on the medication sheet is done immediately following administration." The facility also provided an additional undated policy from their contracted pharmacy regarding medication administration that indicated "Always chart for the medication given at the time it is administered. Narcotic count records should be signed once count of drawer is affected."

F756 SS=E Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 07/22/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 58 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the consultant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 59 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, and act upon drug regimen review (DRR/Medication Regimen Reviews- a monthly summary report of each resident's medication irregularities) for two of three sampled residents (Resident 155, 7) by: 1. Failing to follow the facility's procedure for a DRR reviewed (June 2019, DRR Part 1, Stations 1-3) of providing the Director of Nursing Services and Medical Director with a written, signed and date copy of the Monthly DRR, listing the irregularities found and recommendation for their solutions for Resident 155. This deficient practice had the potential to delay necessary actions including adjusting the residents' medications per the pharmacists recommendations and can lead to adverse effects for 155 residents in Nursing Station 1 to 6. 2. Failing to act upon the Medication Regimen Review to address the pharmacist's recommendation for a Vitamin D level (a laboratory test) for (Resident 7) who has a diagnosis of osteoarthritis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D-osteoarthritis causes pain and stiffness, especially in the hip, knee, and thumb joints). The deficient practice had the potential to result in a delay of or lack of necessary supplementation to minimize Resident 7's osteoarthritis pain. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 60 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a. On June 3, 2019, at 3:26 p.m., during an interview and concurrent record review, of Pharmacist 1's printed email dated June 2, 2019, at 9:27 p.m., the Medical Records Director (MRD), stated Pharmacist 1 sent the facility's DRR to me only, via email, on June 2, 2019 at 9:27 p.m., and not to the licensed nursing staff or the Director of Nursing (DON). The Medical Records Director stated the medical record staff are not here on the weekend (June 2, 2019, Sunday). On June 3, 2019, at 1 p.m., during an interview, and concurrent record review with Licensed Vocational Nurse 13 (LVN 13), when asked, the Desk Nurse/Charge Nurse stated I just received the Nursing Station One, Two and Three DRR from the Medical Records Director (MRD). On June 3, 2019 at 2:49 p.m., during an interview, and concurrent record review with the facility's Consultant Pharmacist, and the facility's Pharmacy service agreement, the facility's Pharmacist stated, "It's not in here, when I'm supposed to deliver the DRR to the facility." I sent the DRR by night email and within 24 hours the report will go to the DON, and Administrator's by standard email. The DRR was sent to the Medical Records Director's (MRD) by email, there was no need to wake up the DON. However, the facilities must develop policies and procedures to address the DRR. The policies and procedures must specifically address appropriate time frames for the different steps in the DRR process. A review of the facility's policy and procedures titled, "Medication Regimen Reviews," dated April 2007, indicated the consultant pharmacist shall review the medication regimen of each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 61 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident at least monthly. Policy Interpretation and Implementation indicated the following: 1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 8. The consultant pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. 9. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and date copy of the report, listing the irregularities found and recommendation for their solutions. b. A review of the admission record indicated Resident 7 was admitted to the facility on August 13, 2010, and readmitted on February 20, 2019, with diagnoses that included osteoarthritis (degeneration of joint cartilage and the underlying bone, and causes pain and stiffness, especially in the hip, knee, and thumb joints) and disorder of bone density and structure (otherwise known as osteoporosis). A review of Resident 7's Physician's Progress Note dated January 26, 2011, indicated Resident 7 had a diagnosis of osteopenia (The difference between osteopenia and osteoporosis is that in osteopenia the bone loss is not as severe as in osteoporosis. That means someone with osteopenia is more likely to fracture a bone than someone with a normal bone density, but is less likely to fracture a bone than someone with osteoporosis. Having osteopenia does increase a person's chances of developing osteoporosis). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and careFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 62 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE screening tool), dated August 11, 2018, indicated Resident 7 was moderately impaired in cognitive status (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decisionmaking. The MDS indicated the resident was totally dependent (full staff performance every time during entire 7- day period) with twoperson extensive assistance for transfer. Resident 7 required extensive one-person assistance with dressing and toilet use. Resident 7 had a care plan for osteoporosis, dated August 11, 2018. Resident 7 did not have a Care Area Assessment (CAA) for osteoporosis for August 11, 2018. A review of 7's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated March 1, 2019, indicated Resident 7 remained moderately impaired in cognitive status in skills for daily decision-making. The MDS indicated the resident remained totally dependent (full staff performance every time during entire 7- day period with two-person extensive assistance for transfer. Resident 7 required extensive one-person assistance with dressing and toilet use. Resident 7's MDS indicated the resident had a diagnosis of osteoporosis without current pathological fracture. A review of Resident 7's Physician's Orders indicated the following: 1. Mechanical soft NAS (no added salt) diet, dated November 9, 2017. 2. Resource Plus (a nutrition drink) 4 ounces (oz) two times a day, dated March 16, 2018. 3. Vitamin D 3 2000 International Units (IU) by mouth every day, dated February 21, 2018. 4. Draw a Vitamin D 3 25 Hydroxy level (a laboratory blood test to monitor vitamin D levels), now, dated June 6, 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 63 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. Multivitamins with minerals 1 tab (tablet) by mouth every day for supplement, dated April 25, 2016. A review of Resident 7's Care Plan for Risk for deformities and pain related to osteopenia, initiated August 11, 2018, indicated a goal that Resident 7 will have no fall incidents in the next 3 months. There were no other interventions that included other supplementation therapy. The care plan did not indicate the need for Vitamin D or Calcium (in the form of food or medication.) A review of Resident 7's Care Plan for Risk for Spontaneous Pathological Fracture related to Osteoporosis, initiated February 21, 2019, indicated Resident 7 would have Vitamin D 3 2000 IU by mouth daily. The intervention included to monitor effect of medication and inform the doctor if the medication is ineffective. There was no indication of which specific lab (laboratory) to monitor, when to monitor, and did not list reference range parameters of when to inform the doctor if the medication was ineffective. When interviewed on June 10, 2019, at 12 p.m., the Assistant Director of Nurses (ADON) stated the facility had never received a medication regimen review (MRR) for Resident 7 from the consultant pharmacist asking for a vitamin D 3 level in the last 2-3 years. During an interview with the Pharmacist Consultant (Pharm 1) on June 7, 2019, he does not always ask for a Vitamin D level on a resident. Pharm 1 stated he would like to get as much data as possible such as ionized calcium level and a magnesium level. Pharm 1 stated he would look through his records to see if he sent a medication regimen review (MRR) for Resident 7 regarding a vitamin D level. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 64 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the MRR, written by Pharm 1, dated November 17, 2016, indicated the following: Considering Resident 7's osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints), consider Vitamin D level to see if Resident 7 needs supplementation to help with current pain. Although, this MRR was from 2016, the lab (laboratory test) was not done until after the survey team asked during the annual recertification survey. Pharm 1 did not make any more recommendations regarding the Vitamin D level after November 17, 2016. During an interview with the ADON on June 10, 2019, at 12 p.m., she stated the facility had not received the November 17, 2016, MRR and was unaware of the MRR until the MRR was re-sent in email by Pharm 1, (during the recertification survey) on the morning of June 10, 2019. A review of the facility's policy and procedures titled, "Medication Regimen Reviews," dated April 2007, indicated the consultant pharmacist shall review the medication regimen of each resident at least monthly. Policy Interpretation and Implementation indicated the following: 1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 8. The consultant pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. 9. The Consultant Pharmacist will provide the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 65 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director of Nursing Services and Medical Director with a written, signed and date copy of the report, listing the irregularities found and recommendation for their solutions.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 07/22/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that metoclopramide (a medication used to treat nausea and vomiting) was not used at an excessive dose or for an excessive duration of therapy in one of five sampled residents (Resident 104.) The deficient practice of failing to use metoclopramide at an appropriate dose or for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 66 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an appropriate duration of therapy increased the risk that Resident 104 may have experienced preventable adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to the use of metoclopramide including, but not limited to: tardive dyskinesia (a medical disorder causing involuntary movements), increased drowsiness, dizziness, and risk of fall. Findings: During a record review, Resident 104's clinical (medical) record indicated that he was initially admitted to the facility on 5/1/18, with diagnoses including, but not limited to: endstage renal disease (ESRD - longstanding disease of the kidneys resulting in the inability of the kidneys to filter waste and excess fluid from the blood) and dependence on renal dialysis (the use of a machine to take over the kidney's function. A review of Resident 104's physician's order dated 10/12/18, indicated that he was receiving metoclopramide 5 milligrams (mg) four times daily (before each meal and at bedtime) to treat nausea and vomiting. A review of the consultant pharmacist's (Pharm 1) note dated 12/2/18, indicated that Pharm 1 had made a recommendation to Resident 104's attending physician to consider whether the metoclopramide could be discontinued citing that "therapy longer than 12 weeks had not been evaluated and cannot be recommended." The section of Pharm 1's consultation note for "follow-through" indicated that the attending physician refused to change the order on 12/6/18." Further review of Pharm 1's consultation note contained no specific clinical rationale as to why the attending physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 67 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE refused to discontinue the metoclopramide. A review of Resident 104's clinical record indicated that the resident had experienced falls on 1/26/19, and 4/15/19, in which he was found on the floor in his room and unable to explain how he had fallen or what had happened. A review of Resident 104's physician's order dated 4/19/19, indicated that the resident was receiving renal dialysis three times weekly on Mondays, Wednesdays, and Fridays in order to treat ESRD. A review of Lexi-Comp (a comprehensive online drug database), metoclopramide therapy for longer than 12 weeks should be avoided due to an increased risk of developing tardive dyskinesia with longer term use. Also, according to Lexi-Comp, the dose of metoclopramide in patients (residents) with ESRD should be limited to 5 mg twice daily (a maximum of 10 mg per day) because decreased kidney function causes it to stay longer in the blood leading to an increased risk of adverse effects when used at higher doses. On 06/07/19, at 10:27 AM, during an interview, Certified Nurse Assistant 1 (CNA 1) stated that she has provided direct care to Resident 104 around four to five times per week for almost a year now. CNA 1 stated that she has not observed Resident 104 having nausea or vomiting in "several months." CNA 1 stated that Resident 104 is too unsteady on his feet to ambulate without assistance, but still occasionally attempts to walk or get out of bed without assistance. On 06/07/19, at 10:36 AM, during an interview, Licensed Vocational Nurse 4 (LVN 4) stated that he has not seen the resident have nausea FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 68 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or vomiting in several months, but stated that the resident is able to communicate his needs and would let the staff know if he was having any kind of problem. On 06/07/19 at 10:55 AM, during a telephone interview, Resident 104's attending physician (MD 2) stated that she continued the order for metoclopramide from his previous physician's order and she never reevaluated the risks versus benefits of the use of metoclopramide because the resident "has been stable and typically changes aren't made to drug regimens for skilled nursing facility patients unless they tell me there's a problem." MD 2 stated there was not a specific clinical rationale for not decreasing the dose due to ESRD or limiting the duration of therapy to 12 weeks and that no one advised her that Resident 104's duration of therapy with metoclopramide exceeded clinical recommendations or that his dosage should be adjusted due to his ESRD diagnosis. MD 2 acknowledged that the risks of using metoclopramide for Resident 104 most likely outweigh the benefits due to the lack of episodes of nausea and vomiting, his age, ESRD diagnosis, history of falls, and possible interactions with other mediations and stated that she "will begin tapering it off." On 06/07/19, at 12:00 PM, during a telephone interview, Pharm 1 stated that he has made several recommendations to discontinue Resident 104's metoclopramide to the facility, but the physicians always deny his requests without providing adequate clinical rationale.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 07/22/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 69 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 70 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the use of psychotropic medications (any medication that affects brain activities associated with mental processes and behaviors) was adequately monitored for effectiveness for two of five sampled residents (Resident 17 and 131.) The deficient practice of failing to ensure that psychotropic medications are monitored for effectiveness and necessity to treat specific, diagnosed, and documented conditions increased the risk that Residents 17 and 131 could have experienced preventable adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to the use of psychotropic medications including drowsiness, dizziness, increased constipation, increased risk of fall, tardive dyskinesia (a medical condition causing involuntary movements), or death. Findings: a. On 06/06/19, at 08:46 a.m., during a record review, Resident 17's clinical record indicated the resident was initially admitted to the facility on 8/30/18, with diagnoses that included major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 71 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 17's physician order dated 10/22/18, indicated that she was prescribed buspirone (a medication used to treat anxiety disorder) 10 mg twice daily for anxiety manifested by "repetitive utterance of 'Oh I see' without apparent reason." A review of Resident 17's care plan titled "AntiAnxiety Drug Therapy" dated 10/22/18, indicated that the Interdisciplinary Team (IDT a group of individuals from different medical backgrounds tasked with creating and revising plans of care for residents living in skilled nursing facilities) had created the goal of "episodes of anxiety will be limited to: 0-1 per week" for the use of buspirone to control Resident 17's "repetitive utterance of 'Oh I see' without apparent reason." A review of Resident 17's "Annual Psychotherapeutic Drug Summary Sheet/Monitoring" for buspirone indicated that in October 2018, she had 18 documented episodes of "repetitive utterance of 'Oh I see' without apparent reason." There were 47 episodes in November 2018, 27 in December 2018, 50 in January 2019, 85 in February 2019, 69 in March 2019 and 113 in April 2019. A review of the "Psychotropic Med Review" document for buspirone indicated that Resident 17's physicians specifically reviewed the use of buspirone to treat anxiety manifested by "repetitive utterance of 'Oh I see' without apparent reason" on 1/10/19, and 4/10/19, making the recommendation on each date to continue buspirone therapy without any changes. A review of the clinical record indicated that there was no evidence that the IDT revised Resident 17's anti-anxiety care plan when it was reviewed in January 2019, or March 2019. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 72 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 06/06/19, at 10:10 a.m., during an interview, Certified Nurse Assistant 2 (CNA 2) stated that she has provided direct care to Resident 17 around 4 times per week over the last two months. CNA 2 stated that she observes Resident 17 say "Oh I see" every day, multiple times per day, but stated that that behavior alone does not cause challenges to providing her care. CNA 2 stated that she does not believe that Resident 17's behavior of uttering the phrase "Oh I see" repeatedly represents a safety risk to the facility's staff or other residents. On 06/06/19, at 10:18 a.m., during an interview, Licensed Vocational Nurse 5 (LVN 5) stated she has provided direct care to Resident 17 for five days per week over the last six months. LVN 5 stated she observes Resident 17 say "Oh I see" a lot. LVN 5 stated based on her observation, the statement of "Oh I see" is Resident 17's attempt to communicate a need to go to the restroom, ask for a drink, or express that she is looking for her family. LVN 5 stated that the only difficulty with the behavior of uttering the phrase "Oh I see" is that the facility's staff can't always determine exactly what need she is trying to express. On 06/06/19, at 10:31 a.m., during an interview, the Director of Nursing (DON) stated Resident 17 has received no psychiatric followup visit since 12/21/18, due to the resident's insurance requirements and stated that she would expect the use of buspirone to be reevaluated given that the target behaviors are exceeding the amount in the care plan goal and it doesn't appear to be effective at controlling the behavior of repeatedly uttering the phrase "Oh I see." b. On 06/06/19, at 01:38 p.m., during a record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 73 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, Resident 131's clinical record indicated the resident she was originally admitted to the facility on 12/25/17, with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), psychosis (a mental disorder characterized by a disconnection from reality), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) A review of Resident 131's physician order dated 1/18/18, indicated the resident was taking risperidone (a medication used to treat mental illness) 0.5 milligram (mg) every day for "psychotic disorder manifested by striking out with caregiver." A review of Resident 131's "Annual Psychotherapeutic Drug Summary Sheet/Monitoring" for risperidone indicated that since her admission to the facility on 12/25/17, to present, Resident 131 has only had one episode of "striking out with caregiver" documented in February 2018. A review of Resident 131's clinical record indicated the consultant pharmacist (Pharm 1) made a recommendation to Resident 131's attending physician to discontinue risperidone or perform a gradual dose reduction (GDR - an attempt to periodically reduce the dose of a medication in order to find the lowest effective dose or to discontinue it completely) on 4/8/18, and 10/6/18. The attending physician declined to perform a GDR or discontinue the risperidone on 5/3/18, and 10/18/18, respectively due to "benefits outweigh risks." A further review of Resident 131's clinical record indicated no additional documentation of a clinical rationale as to why the risks of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 74 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discontinuing or reducing the dosage of risperidone outweighed the benefits of continuing it could be found. On 06/06/19, at 2:15 p.m. , during an interview, CNA 3 stated that she has provided direct care for Resident 131 for around four days per week for the past four months. CNA 3 stated that Resident 131 has never struck out at her and that she has never observed her striking out at any of the facility's other staff. On 06/06/19, at 2:23 p.m., during an interview, LVN 3 stated that she has provided direct care to Resident 131 since February of 2019. LVN 3 stated that Resident 131 has never struck out at her and she has never observed her striking out at any of the facility's other staff. On 06/06/19, at 2:44 p.m., during an interview, the Director of Nursing (DON) stated she knew that Resident 131 has to "go out" for her psychiatric evaluations due to her insurance requirements, but that she cannot find any other psychiatric consult notes or evidence of follow-up psychiatric care since the initial evaluation on 11/29/17. The DON stated that the physician declining the GDR requests was most likely Resident 131's attending physician since she was not being seen by a psychiatrist. The DON confirmed that Resident 131's clinical record did not contain any documented clinical rationale as to why the attending physician would decline a dosage reduction or to discontinue the risperidone when the resident had not had any behaviors of "striking out with caregiver" in nearly 18 months. On 06/06/19, at 3:15 p.m., during an interview, Medical Doctor 3 (MD 3) stated that MD 4 is Resident 131's attending physician and makes treatment decisions for this resident. MD 3 stated that he declined the request for a GDR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 75 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on risperidone on 10/18/18, because he was only filling in for MD 4 at the time. MD 3 stated he did not feel empowered to make changes in Resident 131's treatment plan, as he was not familiar with the resident's previous medical history or any conversations with the other physicians, staff, or family that MD 4 may have had. MD 3 stated that he is semi-retired and works to cover for other physicians on an "as needed" basis which is what he was doing for MD 4 at that time. MD 3 stated MD 4 should be spoken to regarding Resident 131's plan of care or for specific clinical rationale regarding the GDRs for risperidone being declined. On 06/07/19, at 8:18 a.m., during an interview, Social Services Director 1 (SSD 1) stated they tried to contact MD 4 to assess why Resident 131's GDRs for risperidone have been declined, but he did not answer. SSD 1 stated they will try to reach MD 4 again later today. On 06/07/19, at 10:46 a.m., during an interview, the DON stated that they have not been able to reach MD 4 by phone and despite leaving him message, he has not returned their calls. A review of the facility's policy titled "Antipsychotic Medication Use" revised April 2007, indicated that 'For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: persistent or likely to reoccur without continued treatment."

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 07/22/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 76 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). A total twelve medication errors were observed out of a total of 27 opportunities affecting two out of three residents (Residents 58 and 404) observed for medication administration resulting in an overall medication error rate of 44.44%. The deficient practice of administering medications contrary to physician's orders, manufacturer's specifications, or accepted professional standards increased the risk that Residents 58 and 404's health and well-being may be negatively affected. Findings: a. On 06/03/19 at 08:37 a.m., the licensed vocational nurse (LVN 4) was observed administering the following medication to Resident 404: 1. Two aspirin (a medication used to prevent blood clots) 81 milligrams (mg) chewable tablets During a concurrent observation, Resident 404 was observed swallowing the medication whole without chewing or crushing the tablets. On 06/03/19 at 09:08 a.m., during a record review, Resident 404's clinical record indicated that she was admitted to the facility on 5/27/19 with diagnoses that included essential hypertension (high blood pressure). A review of Resident 404's physician's order dated 5/27/19, indicated she was prescribed aspirin 81 mg with instructions to take two tablets every day for six weeks. The order did not specify that the medication should be given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 77 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in a chewable form or that the medication needed to be chewed or crushed. On 06/03/19 at 09:31 a.m., during an interview, LVN 4 stated he gave Resident 404 the chewable form of aspirin because the order did not specify the enteric coated (EC - a protective tablet coating designed to prevent stomach irritation) version. LVN 4 stated the resident did not need to chew the medication and it was not crushed and that Resident 404 swallowed the medication whole. LVN 4 stated he should have clarified the order with the physician since the order was not specific and since the resident swallows the tablets whole, he should have given the EC version to prevent stomach irritation. LVN 4 stated he will clarify the order with the prescribing physician. b. On 06/05/19 at 08:02 a.m., during an interview, licensed vocational nurse (LVN 2) stated she has been working as an LVN for over 20 years, but has only been with this facility for about two weeks. On 06/05/19 at 08:08 a.m., LVN 2 was observed preparing the following medications for Resident 58: 1. Docusate sodium 100 milligrams (mg) tablet (a stool softener) 2. Gabapentin 300 mg capsule (a medication used to treat nerve pain) 3. Memantine ER (extended release - a form of tablet designed to release the medication dose slowly over time) 28 mg (a long acting form of a medication used to treat memory problems) 4. Potassium Chloride ER 20 milliequivalents (mEq) tablet (a potassium supplement) 5. Furosemide 20 mg tablet (a medication used to treat swelling) 6. Digoxin 0.125 mg tablet (a medication used to treat heart conditions) 7. Metoprolol tartrate 25 mg tablet (a medication used to treat high blood pressure) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 78 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8. Montelukast 10 mg tablet (a medication used to treat allergies) 9. Paroxetine 10 mg tablet (a medication used to treat mental illness) 10. Vitamin D 2000 International Units (IU) tablet (a vitamin D supplement) 11. Multivitamin with minerals tablet (a vitamin supplement) 12. Ferrous sulfate 325 mg tablet (an iron supplement) 13. Polyethylene glycol powder (a laxative) During a concurrent interview, LVN 2 stated that Resident 58 needed to have her medications crushed because she had difficulty swallowing, but that she cannot crush the memantine ER or the ferrous sulfate because "those aren't supposed to be crushed." LVN 2 was observed crushing all of the other tablet medications (except for the memantine, ferrous sulfate, and the polyethylene glycol powder) and opening the capsules and mixing all of their contents together into one dosage cup. LVN 2 stated that she mixes all of Resident 58's medications together with applesauce and spoon feeds the mixture to her by mouth. LVN 2 then stated that the dosage of polyethylene glycol powder was "eight ounces" and was observed filling a one-ounce medication cup full of powder. LVN 2 stated this was the correct dose and proceeded to mix the powder into a small cup of juice. LVN 2 entered the resident's room and intended to administer the above medications prepared as described to the resident, but was interrupted for resident safety and asked to recheck her orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 79 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 06/05/19 at 08:35 a.m., during an interview, LVN 2 stated she crushed the potassium chloride tablet but because she was stopped from administering the medications, she now realizes that it was not supposed to be crushed because it is an extended release tablet. LVN 2 stated that she has been crushing the potassium chloride tablets and administering them to Resident 58 for "as long as she can remember." LVN 2 stated that giving potassium chloride in this manner it may cause stomach irritation to the resident. During a concurrent interview, LVN 2 stated she mixed eight ounces of polyethylene glycol powder using a dosage cup and demonstrated she was correct by pointing to the side of the medication cup that read "eight drams (a unit of measure for volume roughly equal to oneeighth of an ounce)." When asked to recheck the order, LVN 2 stated the dose of polyethylene glycol powder should have been 17 grams mixed in eight ounces of water or juice. LVN 2 stated she prepared the wrong dose of the polyethylene as she did not use the cap from the bottle to measure 17 grams as required by the product's manufacturer and could not say how many grams were in the dosage cup. LVN 2 also stated that she "doesn't know" what volume of juice she used to dissolve the powder. LVN 2 was again asked to recheck the physician's order. LVN 2 stated that the 17-gram dose should be dissolve into eight ounces of water or juice. LVN 2 stated she has no way to measure out accurately eight ounces as the cups used for juice do not have markings to determine what volume of liquid they contain. LVN 2 was then asked to ask her supervisor what the correct procedure should be to ensure accuracy of the dose. During a concurrent interview, the assistant director of nursing (ADON) stated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 80 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE potassium chloride tablets should never be crushed and the polyethylene glycol powder should be measured using the cap from the bottle otherwise there's no way to ensure that the resident receives the 17-gram dose. The ADON stated that the juice needs to be measured using the dosage cups calibrated to one ounce to measure out eight ounces. LVN 2 was observed using a dosage cup to fill one of the plastic juice cups whose total volume came out to be around four ounces. During a concurrent interview, the ADON stated that the powder should be split between two juice cups to measure out the full eight ounces specified in the physician's order. LVN 2 stated she not only measured the wrong dose of the polyethylene glycol powder, but also the wrong volume of liquid in which to mix it. LVN 2 stated that she would have given a dose of polyethylene glycol powder that was lower than the amount specified in the physician's order which could have led to the resident developing constipation. On 06/05/19 at 08:57 a.m., Resident 58 was observed swallowing the potassium chloride ER, memantine ER, and ferrous sulfate tablets whole. She was observed being spoon-fed the rest of the medications crushed and mixed together with applesauce, and drinking the polyethylene glycol powder dissolved in eight ounces of juice. A review of Resident 58's clinical record indicated the resident was originally admitted to the facility on 4/9/18 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure.) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 81 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 58's clinical record indicated there was no physician's order to crush any medications and no other evidence that her medications needed to be crushed for ease of administration or that the resident had any difficulty swallowing medications whole could be found. On 06/05/19 at 09:40 a.m., during an interview, the ADON stated that she has removed LVN 2 from her duties of administering medications and sent her home for the rest of the day as a resident safety precaution. On 06/05/19 at 02:44 p.m., during an interview, the ADON stated that there was no physician's order to crush Resident 58's medications and the medications should not have been crushed at all unless there is an order to do so. The ADON stated that LVN 2 made the decision to crush the medications herself even though it was unnecessary for the resident. The ADON stated that when medications are crushed, they should all be separated and each one spoonfed with applesauce individually to the resident. A review of the facility's undated policy entitled "Medication Administration" indicated that "Controlled release medications should not be crushed. Crushing of long-acting or entericcoated medications is allowed ONLY when there is a specific physician's order to do so." The facility also provided an additional undated policy from their contracted pharmacy regarding medication administration that indicated "If you are crushing multiple meds for a resident who has difficulty swallowing then you must crush each med separately and administer each one separately. NEVER mix together." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 82 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F760 Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/22/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for one of three residents (Resident 58) observed during medication administration. This deficient practice resulted in Resident 58 receiving 12 doses of potassium chloride (a potassium supplement) extended release (ER a form of tablet designed to release the medication dose slowly over time) in a crushed form that could have caused symptoms of stomach irritation such as nausea, vomiting, or diarrhea. Findings: On 06/05/19 at 08:02 a.m., during an interview, licensed vocational nurse (LVN 2) stated she has been working as an LVN for over 20 years, but has only been with this facility for about two weeks. On 06/05/19 at 08:08 a.m., LVN 2 was observed preparing the following medications for Resident 58: 1. Docusate sodium 100 milligrams (mg) tablet (a stool softener) 2. Gabapentin 300 mg capsule (a medication used to treat nerve pain) 3. Memantine ER 28 mg (a long acting form of a medication used to treat memory problems) 4. Potassium Chloride ER 20 milliequivalents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 83 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (mEq) tablet 5. Furosemide 20 mg tablet (a medication used to treat swelling) 6. Digoxin 0.125 mg tablet (a medication used to treat heart conditions) 7. Metoprolol tartrate 25 mg tablet (a medication used to treat high blood pressure) 8. Montelukast 10 mg tablet (a medication used to treat allergies) 9. Paroxetine 10 mg tablet (a medication used to treat mental illness) 10. Vitamin D 2000 International Units (IU) tablet (a vitamin supplement) 11. Multivitamin with minerals tablet (a vitamin supplement) 12. Ferrous sulfate 325 mg tablet (an iron supplement) 13. Polyethylene glycol powder (a laxative) During a concurrent interview, LVN 2 stated Resident 58 needed to have her medications crushed because the resident was having difficulty swallowing, but LVN 2 cannot crush the memantine ER or the ferrous sulfate because, "those aren't supposed to be crushed." LVN 2 was observed crushing all of the other tablet medications (including the potassium chloride) and opening the capsules and mixing all of their contents together into one dosage cup with applesauce. During a concurrent interview, LVN 2 stated she mixes all of Resident 58's medications together with applesauce and spoon feeds the mixture of medications to the resident by mouth. LVN 2 entered Resident 58's room and intended to administer the above medications prepared as described to the resident, but was interrupted for resident safety and asked to recheck her orders. On 06/05/19 at 08:35 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 84 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 2 stated she crushed the potassium chloride ER tablet but because she was stopped from administering the medications, she now realizes that it was not supposed to be crushed because it is an extended release tablet. LVN 2 stated she has been crushing the potassium chloride tablets and administering them to Resident 58 for "as long as she can remember." LVN 2 stated that giving potassium chloride in this manner may cause stomach irritation to the resident. During a concurrent interview, the assistant director of nursing (ADON) stated that potassium chloride ER tablets should never be crushed. On 06/05/19 at 08:57 a.m., Resident 58 was observed swallowing the potassium chloride ER, memantine ER, and ferrous sulfate tablets whole. She was observed being spoon-fed the rest of the medications crushed and mixed together with applesauce, and drinking the polyethylene glycol powder dissolved in eight ounces of juice. Review of Resident 58's clinical record indicated the resident was originally admitted to the facility on 4/9/18 with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), and hypertension (high blood pressure.) A review of Resident 58's clinical record indicated there was no physician's order to crush any medications and no other evidence that her medications needed to be crushed for ease of administration or that the resident had any difficulty swallowing medications whole could be found. On 06/05/19 at 09:32 a.m., the ADON provided a handwritten document indicating that LVN 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 85 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE date of hire was 5/6/19 and she has passed medications (including potassium chloride) to Resident 58 on 5/13, 5/14, 5/15, 5/22, 5/23, 5/24, 5/26, 5/27, 5/28, 6/3, 6/4, and 6/5/19. On 06/05/19 at 09:40 a.m., during an interview, the ADON stated she has removed LVN 2 from her duties of administering medications and sent her home for the rest of the day as a resident safety precaution. On 06/05/19 at 02:44 p.m., during an interview, the ADON stated there was no physician's order to crush Resident 58's medications and the medications should not have been crushed at all unless there is an order to do so. The ADON stated that LVN 2 made the decision to crush the medications herself even though it was unnecessary for the resident. The ADON stated when medications are crushed, they should all be separated and each one spoonfed with applesauce individually to the resident. A review of Resident 58's medication administration record (MAR - a record of each medication given to a resident) from May and June of 2019 confirmed the information provided by the ADON indicating that LVN 2 had crushed and given a total of 12 doses of potassium chloride ER to Resident 58 on the dates mentioned above. A review of Resident 58's clinical record indicated it contained no evidence the resident had experienced any adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to being administered crushed potassium chloride ER tablets. A review of the facility's undated policy entitled "Medication Administration" indicated that "Controlled release medications should not be crushed. Crushing of long-acting or entericFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 86 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE coated medications is allowed ONLY when there is a specific physician's order to do so."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 07/22/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Label medications with an "open date" when required to ensure that they are discarded in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 87 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with the timeline specified by the manufacturer in one of two observed medication rooms (Medication room for nursing stations 4, 5, and 6) and two of three observed medication carts (Medication carts 4 and 5). 2. Discard any medications which have expired for two of three observed medication carts (Medication carts 4 and 5). The deficient practices of failing to store medications appropriately according to the manufacturer's requirements, label medications with an "open date" when required, and discard medications which are expired increased the risk of the facility's residents receiving medications which may have become ineffective or toxic resulting in a negative impact to their health and well-being. Findings: On 06/03/19 at 11:24 a.m., during an observation of the medication room for nursing stations 4, 5, and 6, a bottle of lorazepam (a medication used to treat mental illness) 2 milligram (mg) per milliliter (ml) was found in the medication refrigerator opened, with the seal broken, but not labeled with an "open date." A review of the manufacturer's labeling for lorazepam 2 mg/ ml oral solution indicated to "discard opened bottle after 90 days." During a concurrent interview, the assistant director of nursing, acknowledged that the bottle had been opened and the seal had been broken, and despite it not yet having been used, it was not labeled with an "open date." On 06/03/19 at 11:50 a.m., during an observation of medication cart #4 the following storage issues were found: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 88 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. A protective foil pack containing vials of ipratropium/albuterol nebulizer solution (a medication used to treat breathing problems) was found to be opened but not labeled with an "open date." 2. A protective foil pack containing vials of levalbuterol nebulizer solution (a medication used to treat breathing problems) was found to be opened but not labeled with an "open date." 3. A bottle of glucometer (a device used to test blood sugar) control solution (a solution used to test whether a glucometer is reading blood sugar accurately) was found with a discard date of 5/3/19. Review of the product labeling for ipratropium/albuterol nebulizer solution indicated that "once removed from the foil pouch, the individual vials should be used within two weeks." A review of the product labeling for levalbuterol nebulizer solution indicated that "once the foil pouch is opened, the vials should be used within two weeks." On 06/03/19 at 12:05 p.m., during an interview, the licensed vocational nurse (LVN 3) stated the foil packets for the nebulizer solution for both ipratropium/albuterol and levalbuterol were both open, but not labeled with an open date. LVN 3 stated the discard date marked on the glucometer control solution was most likely the "open date" as that is how it is usually marked but acknowledged that if the discard date is 5/3/19, then the product would be considered expired. LVN 3 indicated she would discard all of the products stored incorrectly and reorder them from the pharmacy. On 06/05/19 at 10:13 a.m., during an observation of medication cart #5, the following storage issues were found: 1. One bottle of latanoprost 0.005 percent (%) ophthalmic solution (a medication used to treat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 89 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE eye conditions) found opened but not labeled with an "open date." 2. One bottle of nitroglycerin 0.4 mg sublingual tablets (a medication used to treat chest pain) with an open date of 9/19/17. According to Lexi-Comp (a comprehensive online drug database), the manufacturer's storage specifications for latanoprost 0.005% ophthalmic solution are as follows: "Store intact bottles under refrigeration at 2 degrees C to 8 degrees C (36 degrees F to 46 degrees F) ... Once opened, the container may be stored at room temperature up to 25 degrees C (77 degrees F) for six weeks." Review of the facility's undated policy entitled "Medications requiring notation of date opened" indicated that sublingual nitroglycerin tablets expire "one (1) month after opening." During a concurrent interview, LVN 4 stated that the nitroglycerin tablets found with the open date of 9/19/17 are considered expired. LVN stated that the bottle of latanoprost ophthalmic solution was not labeled with an "open date" and thus he intended to have the pharmacy replace it since he was unsure how long it had been kept at room temperature. A review of the facility's undated policy entitled "Storage of Medications" indicated that "Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier" and "Outdated, contaminated, or deteriorated medications ... are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 90 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/22/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: The facility failed to ensure one of one Dietary Staff utilized good hygienic practices techniques, when removing soiled food, and changing dishwashing task, after handling soiled equipment and utensils and dishes. This deficient practice had the potential for possible cross-contamination between potentially hazardous foods (PHFs), dishes that require time and proper hand washing in order to prevent bacterial growth. Findings: On June 3, 2019 at 7:20 a.m., during the initial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 91 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tour observation of the facility's kitchen, the facility's Dishwasher Aide 1 (DA 1), was observed loading dirty dishes into the facility's low temperature dishwashing machine without washing his hands with soap and warm water, or wearing disposable gloves, prior to removing the sanitized dishes from the dishwasher and placing them on the utility racks. On June 3, 2019 at 7:38 a.m., during concurrent interview and observation with DA 1 at the same time, DA 1 stated (via of a translator), he made a mistake, and knew to wash his hands before and after handling dirty and clean dishes. However, DA 1 did not prevent cross-contamination before washing the facility's dishes. On June 3, 2019 at 7:38 a.m., during a concurrent interview and observation with the Registered Dietitian (RD), the RD according to infection control policy, DA 1 could have spread contamination between the Potentially hazardous Foods (PHFs) from dirty dishes, that requires time proper hand washing in order to prevent bacteria growth in the facility. A review of the facility's policy and procedure titled, "Sanitation and Infection Control: Dishwashing Procedures (Dish machine)," indicated under Policy: The dish machine will be used to clean all the dishes and equipment. Dish machines will be used per manufacturer guidelines. Under Procedures the following: 6. Dish-machine temperature logs will be kept on file in the DSS's office for a minimum of one year. 7. Facilities are to follow the manufacturer's recommendation in dishwashing to ensure sanitation of dishes and utensils. 8. It is recommended to remove all food debris before loading them in the dish washer; it is recommended to remove all food debris from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 92 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE before loading them in the dishwasher; it recommended to soak silverware and other dishes if necessary. 9. All the dishes should be inspected after coming out of dish-machine and if the dishes are not clean then they should be washed again in dish-machine. 10. Allow racks of dishes/trays/utensils to air day. If drying space is not ample for dishes to air, use utility carts. Do not use towels to dry dishes. Do not and stack wet dishes or trays. 11. To avoid cross contamination, it is recommended two employees hand dishwashing. One employee should handle soiled dishes, trays and carts and the other employee should handle clean, dishes, trays and carts. 12. If only one employee is available to wash and handle clean and soiled dishes, the employee must wash hands thoroughly before handling clean dishes, trays and carts. 13. The dish-machine should be drained, and filters emptied after each meal service.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 07/22/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 93 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 94 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the clinical records were accurately documented for one of one sampled resident (Resident 128) by failing to enter telephone transfer order. The facility transferred the resident to a general acute hospital (GACH) without a proper physician's order to transfer the resident. This deficient practice had a potential to negatively affect the delivery of services for Resident 128. Findings: A review of Resident 128's Admission Record indicated the resident was originally admitted to the facility on January 23, 2017, and readmitted on March 16, 2019 with diagnoses of muscle weakness and seizure disorder (a medical condition that is characterized by episodes of uncontrolled electrical activity in the brain). A review of Resident 128's Minimum Data Set (MDS- a standardized assessment and screening tool) dated May 22, 2019, indicated Resident 128`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicated the resident is totally dependent on staff for walking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 95 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on and off the unit and using the bathroom. On June 5, 2019, at 9:50 a.m., at a concurrent record review and interview with the Assistant Director of Nursing (ADON), she stated that she was unable to find a physician transfer order in the resident's chart. Resident 128 was discharged to a general acute care hospital (GACH) on May 1, 2019. On June 5, 2019. at 2:20 p.m., during an interview with the director of medical record department, he stated that he was unable to find any record of physician transfer order. He stated the physician transfer order is supposed to be located in the resident's chart. A review of the facility's policy and procedure dated December 2008, titled Telephone Orders indicated orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 07/22/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 96 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 97 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the infection prevention and control program (IPCP - a comprehensive program used to help recognize, prevent, and help control the spread of infection in the facility) by failing to perform adequate infection surveillance to determine if a resident had a true infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms) for one of three sampled residents (Resident 100.) The deficient practice of failing to perform adequate infection surveillance increased the risk that Resident 100 may have experienced preventable adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to unnecessary antibiotic (medications used to treat infections) such as nausea, vomiting, and diarrhea. Findings: During a record review, Resident 100's clinical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 98 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record indicated that she was admitted to the facility on 2/24/19 with diagnoses including pneumonia (an infection in the lungs.) A review of Resident 100's physician order dated 6/1/19, indicated the resident was prescribed cefuroxime (an antibiotic used to treat bacterial infection) 250 milligrams (mg) twice daily for 7 days. On 06/07/19, at 2:03 p.m., during a telephone interview, the infection control nurse (ICN) stated she is not scheduled to work today, but she is the facility's infection preventionist (IP person responsible for implementing the facility's IPCP) and responsible for performing the infection surveillance duties as part of the implementation of the facility's IPCP. The ICN stated she works as the IP full time and dedicates 40 hours per week to infection control duties. The ICN stated she usually performs the portion of the infection surveillance for which she is responsible the day after antibiotic therapy is initiated for a resident's suspected infection. A review of Resident 100's "Surveillance Data Collection Form Attachment B for Respiratory Tract Infections" indicated that the treatment nurse had performed the initial assessment portion of the surveillance on 6/1/19 when antibiotic therapy was initiated, but that the ICN had not completed her portion of the infection surveillance form and had made no determination as to whether Resident 100 had a true infection or not by 6/7/19 - the final day of her antibiotic therapy. On 06/07/19 at 2:51 p.m., during an interview, the director of nursing (DON) stated that the ICN failed to complete the determination of whether or not the resident has a true infection per the facility's policy. The DON acknowledged that today is the last day of Resident 100's antibiotic therapy and that any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 99 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE effort from the ICN at this point would be of questionable value.

F881 SS=D Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 07/22/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: 1. Include in its infection prevention and control program (IPCP - a comprehensive program used to help recognize, prevent, and help control the spread of infection in the facility) clinical criteria used to guide the selection and duration of antibiotic (medications used to treat infections) therapy when necessary to treat residents who have been determined to have a true infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms). 2. Establish a system to monitor for the use of antibiotics in the facility. These deficient practices increased the risk that: 1. Residents may receive treatment with antibiotics not best suited to treat their infections with the potential for resulting in their FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 100 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infection not being treated appropriately or completely. 2. Residents may experience preventable adverse effects (unwanted, uncomfortable, or dangerous effects which may impair a resident's ability to function at their highest possible level of physical, mental, and psychosocial well-being) related to antibiotic such as nausea, vomiting, and diarrhea. 3. Antibiotic therapy may become ineffective at treating residents' future infections. Findings: On 06/07/19 at 2:03 p.m., during a review of the facility's IPCP, the IPCP did not contain any written protocols or clinical criteria to help guide the appropriate selection and duration of antibiotic therapy in residents determined to have true infections. The IPCP also did not contain any data or the trends of antibiotic usage or any tools with which to communicate antibiotic prescribing trends to the facility's prescribing physicians. During a concurrent telephone interview, the infection control nurse (ICN) stated that she served as the facility's infection preventionist (IP - individual selected by the facility to be responsible for implementing the IPCP.) and works 40 hours per week exclusively on infection control duties. The ICN stated there is no data kept on trends of antibiotic usage, no communication of antibiotic prescribing trends to the facility's prescribing physicians, and no written protocols on the selection of antibiotics present in the IPCP. The ICN stated that antibiotic selection to treat infections is at the sole discretion of the prescribing physician and that the facility does not evaluate their use after they are prescribed. The ICN stated the facility is trying to "rebuild" its antibiotic stewardship program and that she has only been in the IP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 101 of 102 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056084 (X3) DATE SURVEY COMPLETED 06/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ASTORIA HEALTHCARE CENTER 14040 Astoria St Sylmar, CA 91342 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE role for a few months. On 06/07/19, at 2:35 p.m., during an interview, the director of nursing (DON) stated the facility does not track antibiotic prescribing or communicate any antibiotic prescribing trends or data back to the prescribers but that they "will start." A review of the facility's undated policy entitled "Antibiotic Stewardship Program" indicated, "The IP will report on number of antibiotics prescribed (e.g. days of therapy and the number of residents treated each month to the Consultant Pharmacist" and "The IP and Consultant Pharmacist will be responsible for collecting and reporting data to the ICC (infection control committee)." Further review of the policy indicated that "The IP or Medical Director will communicate with physicians on their individual prescribing patterns of cultures ordered and antibiotics prescribed, as indicated." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2WPU11 Facility ID: CA920000002 If continuation sheet 102 of 102