Berkeley Square Retirement Cen

In the surveyor’s words

From the most serious findings on record at Berkeley Square Retirement Cen, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based on document review, staff interview, and policy review, the facility failed to ensure food temperatures were documented at the tray line for each meal served from the kitchenettes in the [NAME] and [NAME] Dining Rooms. This had the potential to affect all residents in the facility. The facility census was 27. Findings include:1. Review of facility document titled Trayline Taste & Temperature Log with a revised date of September 2018 revealed that tray line food temperatures were not documented for meals served from the kitchenette in the [NAME] Dining Room for dinner on 03/30/26, dinner on 03/31/26, lunch and dinner on 04/01/26, lunch and dinner on 04/02/26, dinner on 04/07/26, lunch and dinner on 04/08/26, and lunch and dinner on 04/10/26.Interview on 04/13/26 at 9:38 A.M., with the… […]

• No harm, potential for more than minimal, widespreadF812Aug 4, 2022

  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 [DATE] 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 [DATE] at 12:31 P.M. revealed Dietary Technician #51 delivered a hamburger on a plate to Resident #17 in the dining room. […]

• No harm, potential for more than minimal, isolatedF657Apr 16, 2026

  Based on record review, interviews, and policy review the facility failed to document completion of care conferences at the required intervals. This affected two residents (#04 and #15) of 12 residents reviewed for care conferences. The facility census was 27.Findings include:1. Review of the medical record of Resident #04 revealed an initial admission date of 10/14/16 and a re-admission date of 01/31/20. Diagnoses included Parkinson's disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder.Review of the most recent significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was… […]

• No harm, potential for more than minimal, isolatedF684Apr 16, 2026

  Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents received treatment in accordance with professional standards of practice when a resident was not reevaluated for hyperglycemia. This affected one (Resident #03) of five residents reviewed for unnecessary medicine. The facility census was 27.Findings Included:Medical record review revealed Resident #03 had an admission date of 01/05/26. Diagnoses included Alzheimer's, diabetes mellitus type II, and depression Review of the current physician orders for Resident #03 included Humalog (an insulin medication to lower blood sugar) subcutaneous solution pen-injector 100 unit/milliliter (u/ml) per a sliding scale before meals, Lantus (an insulin medication to lower blood sugar)… […]

• No harm, potential for more than minimal, isolatedF756Apr 16, 2026

  Based on medical record review, observation, review of the medication regimen review, staff interview, and policy review, the facility failed to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist were acted upon. This effected one (Resident #08) of five residents reviewed for medication regimen review. The facility census was 27.Findings Included:Review of the medical record for Resident #08 revealed an admission date of 11/24/25. Diagnoses included Parkinson's, dementia, hypothyroidism. […]