Berrien Oaks Nursing And Rehab Center
Inspection Findings
F-Tag F0759
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or potential for actual harm
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) (Resident 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 Resident 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 Resident 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 Resident 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.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BERRIEN OAKS NURSING AND REHAB CENTER in NASHVILLE, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NASHVILLE, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BERRIEN OAKS NURSING AND REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.