Inspection·September 16, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, and review of the facility policy, the facility failed to follow the physician's order to treat the resident's pressure wounds and failed to routinely assess the resident's pressure wounds. This affected one (Resident #11) of three residents reviewed for pressure wounds. The facility identified eight residents with pressure ulcers. The facility census was 29. Residents Affected - Few Findings include: Review of the medical record revealed Resident #11 had an admission date of 07/29/24. Diagnoses included chronic systolic heart failure, vertebra osteomyelitis, and Parkinson's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Review of the skin only evaluation dated 07/29/24 revealed Resident #11 had the following skin concerns: left heel, buttocks excoriation, right buttocks medial, back excoriation, right elbow skin tear not painful, right and left lower legs discoloration, and right shin tear. There were no measurements or description of the wounds. Review of the plan of care dated 07/29/24 revealed Resident #11 was at risk for potential for skin breakdown related to bowel incontinence, catheter tubing in use, decreased mobility, previous issues with Moisture Associated Skin Damage (MASD) on right inner buttocks, stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) to the left heel. Deep tissue injury (purple or maroon area of discolored intact skin due to damage or underlying soft tissue) to right buttocks, yeast under right and left arm. Many refusals of care and treatment to be completed. On 08/06/24, a wound consultant assessed Resident #11's wounds and included the following pressure areas: right buttock was a deep tissue injury (DTI) and showed deterioration. Left heel stage III smaller in size. Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the skin only evaluation dated 08/15/24 revealed Resident #11 had wounds which included the following: left heel (DTI), right heel (DTI), right buttock (marked as open lesion), and left buttock (marked as open lesion). There were no measurements or descriptions of the wounds. Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. (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 09/16/2024 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)