Health inspection·December 9, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure Resident #62 received all medication doses a physician ordered intravenous (IV) antibiotic. This affected one (Resident #62) of three residents reviewed for medication administration. The facility census was 61. Findings include:Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis, sepsis, bacteremia, urinary tract infection (UTI), acute kidney injury (AKI), anemia, polyneuropathy, hyperlipidemia, obstructive sleep apnea (OSA), obstructive and reflux uropathy, and calculus of kidney with calculus of ureter. Resident #62 was discharged on 11/22/25.Review of facility November 2025 infection control log revealed Resident #62 was receiving IV antibiotics beginning 11/11/25 and ending on 11/22/25.Review of Resident #62 history and physical completed by Medical Director #600 on 11/12/25 revealed Resident #62 was admitted to the facility to continue antibiotics and physical therapy. Resident #62 was admitted to the facility for IV antibiotics following a hospital admission due to urosepsis, AKI with acute pyelonephritis, found with pseudomonas UTI and bacteremia.Review of Resident #62 Minimum Data Set (MDS) assessment completed on 11/18/25 revealed the resident was on an antibiotic, IV medications, and had central IV access.Review of Resident #62 physician's orders revealed an order placed my Medical Director #600 on 11/11/2025 for Cefepime-Dextrose IV Solution Reconstituted 2-5 gram (GM)-%50 milliliter (ML). Use one dose IV every 12 hours for pyelonephritis for 10 days. With the order discontinued on 11/22/25.Review of Resident #62 orders revealed an order placed on 11/11/25 for a Peripherally Inserted Central Catheter (PICC) line to be maintained with a transparent dressing and a dressing change every six days.Review of Resident #62 Medication Administration Record (MAR) for November 2025 revealed on 11/18/25 at 6:00 P.M. the ordered IV antibiotic [Cefepime-Dextrose IV Solution Reconstituted 2-5 GM-%50 ML every 12 hours had no documented evidence of administration or refusal.Interview on 12/09/25 at 2:15 P.M. with Licensed Practical Nurse (LPN) #47 revealed if there is a medication not signed off on the MAR you would check to see if the medication was still present in its storage area, you would then determine if the medication had been given or not. After you administer a medication to a resident, you mark it off as administered on the MAR. If a resident refuses medication, you are to document that and notify the physician. Interview on 12/09/25 at 3:00 P.M. with LPN #95 revealed you check the resident's MAR to ensure a medication was given, and any medication you give, you mark it off on the MAR.Review of Resident #62's progress notes revealed no documentation of a rationale for IV antibiotics not being administered on 11/19/25 at 6:00 P.M., no documentation of a physician notification, and no documentation of attempts to contact the pharmacy regarding missing IV medication or missing IV medication dose, and/or no documentation of resident refusal of the medication. Interview on 12/09/25 at 12:45 P.M. with the Director of Nursing (DON) on confirmed on 11/19/25, Resident #62's MAR revealed no documented evidence the IV antibiotic was administered.Review of facility policy titled Medication Administration, effective 06/21/2017, revealed Residents Affected - Few Page 1 of 2 366352 366352 12/09/2025 Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications will be administered in accordance to applicable state, local, and federal laws consistent with accepted standards of practice. The resident has the right to refuse medication. It is, however, the nurses responsibility to review with the resident the consequences of their refusal and document it accordingly. If a medication is unavailable, contact the pharmacy and document it accordingly. After medication administration document medication administration with initials on the MAR immediately after administering medication to each resident. This deficiency represents noncompliance investigated under Complaint Number 2677502. 366352 Page 2 of 2