Health inspection·August 8, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observation, staff interview, review of facility policy, and review of the online resource, the facility failed to discard outdated resident medications. This affected Resident #3 for eye drops and had the potential to affect six residents (#8, #17, #22 , #25, #28, #85 and #86) for antacid medication. The facility census was 30. Findings include: 1. Review of record for Resident #3 revealed an admission date of 03/10/16 and a diagnosis of end stage heart failure. Review of the physician orders, dated 05/03/18, revealed an order for the resident to receive artificial tear solution instilled two drops in both eyes threes time per day for dry eye. Review of Medication Administration Record (MAR) for August 2019 for Resident #3 revealed resident received artificial tear solution instilled to both eyes per the physician's order. Observation and interview on 08/07/19 at 10:23 A.M. with Licensed Practical Nurse (LPN) #242 revealed an opened bottle of artificial tear solution labeled with Resident #3's name and dated 06/25/19. The LPN confirmed that the bottle of artificial tear solution was used for Resident #3 and had been dated 06/25/19 to indicate when it had been opened. Interview with the Director of Nursing (DON) on 08/07/19 at 4:15 P.M. confirmed the artificial tear solution did not contain manufacturer instructions regarding when the medication should be discarded once opened. Review of the International Pharmacopoeia, Seventh Edition, dated 2017, revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened. Review of facility policy titled Storage of Medications, dated 07/25/19, revealed all multidose vials of medications are to be dated and initialed by the nurse opening the vial and indicating the date of opening. 2. Observation on 08/07/19 at 10:07 A.M. of the rehabilitation unit medication cart with LPN #238 revealed the cart contained an opened house stock bottle of Maalox liquid (over the counter indigestion medication) with a manufacturer's expiration date of 07/2019. (continued on next page) 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 Page 1 of 3 Event ID: 366053 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366053 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Square Retirement Cen 100 Berkeley Drive Hamilton, OH 45013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)