Berrien Oaks Nursing And Rehab Center

Based on observation, staff interview, record review, and review of the facility policy and procedure titled Medication Administration Policy- General, the facility failed to ensure that the medication error rate was less than five percent. A total of 30 opportunities were observed with six errors, for one of four residents (R) (R7) by one of three nurses, for a medication error rate of 16.6 percent.Findings include:

Review of the facility policy and procedure titled Medication Administration Policy- General, dated 8/7/2023, documented to verify that the medication name and dose are correct when compared to the medication order on the medication administration record.

Review of the Clinical Physician's Orders and the October 2025 Medication Administration Record (MAR) for R7 revealed the following physician's orders: ciprofloxacin HCL (hydrochloride) otic solution, instill four drops in the right ear once a day for otitis (inflammation of the ear) for seven days, cetirizine HCL 10 milligrams (mg) one tablet by mouth once a day, fluticasone propionate suspension 50 micrograms one spray in each nostril once a day, magnesium oxide supplement 400 two tablets by mouth once a day, docusate sodium 100 mg one capsule by mouth two times a day, and Refresh ophthalmic solution 1.4-0.6 percent instill one drop in both eyes two times a day.

Review of the MAR for R7 revealed that the cetirizine, fluticasone, magnesium oxide, docusate sodium, Refresh ophthalmic solution, and ciprofloxacin otic solution were scheduled to be administered at 8:00 am.Observation of medication pass with the Director of Nursing (DON) on 10/7/2025 at 10:00 am revealed she administered 8:00 am medications to R7 to include sertraline, omeprazole, nortriptyline, Eliquis, Baclofen, and gabapentin that had been prepackaged by the pharmacy.

The surveyor instructed the DON to inform the surveyor if there would be any medications not given that were ordered to be given at that time.

The DON voiced understanding and continued to administer the prepackaged medications.

The DON failed to administer the over-the-counter medications of cetirizine, fluticasone, magnesium oxide, docusate sodium, and Refresh ophthalmic solution, and the ciprofloxacin otic solution.

During an interview with the DON on 10/7/2025 at 11:57 am, she stated she was unable to locate the ciprofloxacin otic drops.

She stated she called the pharmacy and was told the medication was delivered on the evening of 10/6/2025.

When the surveyor inquired about the omitted over-the-counter medications, the DON asked another nurse working on that unit to come and show her where they were located.

Those medications were located in the top drawer of the medication cart.

She stated that this was the first time she had to work on the medication cart.During an interview with the Administrator on 10/7/2025, he stated that if he had known the DON was working the medication cart, he would have told her to assign the cart to another nurse.

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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