Peace Care St Ann's

Propionate External cream 0.05%.

Apply to affected areas topically every day and evening shift for wound care until 8/26/2025 23:59, dated 8/6/2026.A review of Resident #4's August 2025 MAR revealed blank spaces for the above corresponding PO on 8/16/2025 and 8/18/2025 on day shift.A review of Resident #4's August 2025 Progress Notes (PNs) did not reveal documentation that the PO was administered.On 8/21/2025 at 9:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that once a medication was given it was signed out on the MAR.

She further stated that if a resident had refused their medications or if it was held, the nurses had to document the reason on the MAR.

She further indicated that the MAR could not be left blank.On 8/21/2025 at 1:16 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the MAR was signed after the nurse administered medications to the resident.

She further stated that if a resident refused a medication, the nurse would document a refusal code on the MAR.

The DON confirmed that Resident #3 and Resident #4's MARs had blank spaces.

She indicated that that the expectation was that there was not supposed to be any blank spaces on the MAR.

The DON stated that it was important that the nurses sign out the MAR as it revealed whether the medication was administered or not.A review of the facility's undated policy titled Medication Administration, revealed under Policy, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.

Under Policy Explanation and Compliance Guidelines, 20.

Sign MAR after administered. 22.

Report and document any adverse side effects or refusals.NJAC 8:39-23.2 (a)

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