Astoria Place Living & Rehab

Based on interview and record review the facility failed to ensure that a resident's medications were documented as administered, as ordered by the physician.

This failure affects one resident (R1) out of three residents reviewed for quality of care.Findings include:On 08/12/2025 at 12:30pm V2 (DON/Director of Nursing) presented R1's MARs (medication administration records) to the surveyor, which were reviewed.

There were missing entries of nurses' signatures/initials or codes on the MARs for June 2025 (6/1/2025 to 6/30/2025).R1's diagnoses include Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder.There were missing entries of nurses' signatures/initials or codes on R1's medication administration record for the following medications, dates, and times:On 06/08/2025 at 6:00am Levothyroxine Sodium (Hormone) 50 mcg (microgram) tablet- Give 1 Tablet by mouth in the morning.On 06/08/2025 at 6:00am Pantoprazole Sodium (Antiulcer) Oral Tablet Delayed Release 40 mg (milligrams)Give 1 tablet by mouth in the morning.On 06/08/2025 at 6:00am Advair Diskus (Corticosteroid) Aerosol Powder Breath Activated 100-50 mcg/dose-1 inhalation inhale orally every 12 hours.On 8/12/2025 at 1:37pm V4 (ADON (Assistant Director of Nursing)/RN (Registered Nurse) stated the nurses are responsible for administering the medications to the residents.

The nurse is to document in the electronic medication administration record that the medication was administered to the resident. V4 stated there are codes the nurses can use on the electronic medication administration record when a resident refuses the medication, or the resident is out of the facility on pass. V4 stated if a there is a blank space on the medication administration record for a scheduled dose of medication to be administered to the resident on a certain date and time in my professional opinion this would indicate that the medication was not administered to the resident.On 8/12/2025 at 3:00pm V2 (DON/Director of Nursing) stated the nurse are responsible for administering the medications to the residents.

The nurses are to document on the electronic medication administration record after a medication is administered to the resident.

There are codes the nurses can use on the electronic medication record when a resident refuses the medication or if the resident is out on pass from the facility or hospitalized .

Reviewed the Facility's Policy titled Medication Pass which documents, 7.

After medication is administered to each resident, sign MAR (medication administration record) that it was given.Reviewed facility's Registered Nurse Job Description, which documents, in part,

• Completes medical records documenting care provided and other information in accordance with

nursing policies while maintaining strict confidentiality.

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.

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