Inspection·August 4, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and policy review, the facility failed to store and serve food in a sanitary manner. This affected two residents (#17 and #24) who were observed in the dining room. This had the potential to affect all 28 residents who receive food from the kitchen. The facility census was 28. Findings include: 1. Observations on 08/01/22 at 12:27 P.M. revealed State Tested Nurse Aide (STNA) #6 picked up one half of a ham salad sandwich in her bare hand and held it up to Resident #24's mouth. STNA #6 placed her bare hand inside an individual-sized bag of cheeses puffs and placed a chip in Resident #24's hand. Observation on 08/01/22 at 12:31 P.M. revealed Dietary Technician #51 delivered a hamburger on a plate to Resident #17 in the dining room. STNA #6 asked Resident #17 if she wanted mustard, took the top bun off the sandwich with her bare hand, squeezed mustard on top of the hamburger patty, replaced the bun, and patted the bun down with her bare hand. STNA #6 did not sanitize her hands before she continued providing feeding assistance to both Resident #24 and Resident #17. During an interview on 08/01/22 at 12:39 P.M., STNA #6 verified she had touched both Residents #24's and #17's food with her bare hands. STNA #6 stated she had thought if she used hand sanitizer, it was ok to touch food with her bare hands. 2. Observation made on 08/01/22 at 9:14 A.M. revealed the walk-in refrigerator located in the hallway contained multiple expired eight ounce (oz) cartons of milk including: one carton chocolate milk dated 07/13/22, one carton 2% white milk dated 07/23/22, one chocolate milk dated 07/25/22, six cartons 2% white milk dated 07/25/22, and 19 cartons 2% white milk dated 07/31/22. Observation made on 08/01/22 at 9:23 A.M. revealed the reach-in refrigerator located in the kitchen contained multiple bins of expired left over foods including one half-pan labeled chicken and rice prepared on 07/16/22 with a discard date of 07/21/22, one gallon-sized re-sealable bag of cooked hamburgers labeled prepared on 07/28/22 with a discard date of 07/31/22, one labeled quarter pan of chili prepared on 07/19/22 with a discard date 07/31/22 and one labeled plastic container with two and half quarts of black olives opened on 07/20/22 with a discard date of 07/30/22. During an interview on 08/01/22 at 9:29 A.M., Dietary Staff #55 verified the reach-in refrigerator contained multiple pans of leftover foods stored beyond their discard date. Dietary Staff #55 stated leftover foods were labeled with the date they were prepared and discarded with in three to seven (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 2 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 08/04/2022 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)