Health inspection·May 23, 2022

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** 2. Medical record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #9 include neurofibromatosis, obesity, muscle weakness, dysphagia, depression, and disorder of the bone. Residents Affected - Few Review of Resident #9's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident had one unstageable unhealed pressure ulcer during the assessment period. Review of wound documentation dated 05/10/22 revealed the left heel was staged as unstageable with measurements of 2.4 cm by 3.5 by undetermined depth. Review of Resident #9's wound documentation dated 05/17/22 revealed the resident has a stage three pressure ulcer on the left heel measuring 25 cm by 2.9 cm by 0.3 cm. Review of Resident #9's physician orders revealed an order dated 03/01/22 to cleanse heel with wound cleaner, pat dry. Apply silver alginate and cover with an ABD and wrap with kerlix every day shift. Review of the TAR for March 2022 revealed the resident did not receive the dressing change to her left heel on 03/03/22, 03/18/22, 03/22/22, and 03/31/22. Review of Resident #9's physician orders revealed an order dated 04/18/22 for wound care to the left heel; cleanse with wound cleaner, pat dry. Apply medihoney and calcium alginate and cover with an ABD and wrap with kerlix on Mondays, Wednesday, and Fridays and as needed. Review of Resident #9's TAR for April 2022 revealed the resident's dressing change was not documented as completed on 04/19/22, 04/24/22 and 04/25/22. Review of Resident #9's physician orders revealed an order dated 05/15/22 for wound care to the left heel; cleanse with wound cleaner, pat dry. Apply silver alginate and cover with an ABD and wrap with kerlix on Mondays, Wednesday, and Fridays and as needed. Review of Resident #9's TAR for May 2022 revealed the resident's dressing change was not documented as completed on 05/13/22 and 05/18/22. Further review of Resident #9's medical record revealed no documentation for rational of missing dressing changes. Interview on 05/18/22 at 11:00 A.M. with Resident #9 revealed the resident was alert and oriented during the interview. Resident #9 stated knowledgeable of when her wound care was supposed to be completed. Resident #9 reported there were many times the wound care did not get completed. Resident #9 stated the wound physician had changed her dressing on 05/16/22 but the dressing had not been changed since the previous Wednesday (05/11/22). Interview on 05/18/22 at 11:45 A.M. with Licensed Practical Nurse, (LPN) #392 revealed missing documentation on the TARs indicated the care had not been provided. Per LPN #392, all care was to be documented at the time of completion in the medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 2 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility undated policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revealed the physician will authorize pertinent orders related to wound treatments including wound cleaning and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. Based on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to ensure wound dressings were applied and completed according to physician orders. This affected two residents (#9 and #56) out of ten residents reviewed for wound care. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #56 was admitted on [DATE]. Diagnosis included sepsis, emphysema, unspecified protein-calorie malnutrition, chronic obstructive pulmonary disease, panlobular emphysema, acute respiratory failure with hypoxia, muscle weakness, nonrheumatic mitral (valve) insufficiency, supraventricular tachycardia, unspecified atrial fibrillation, malignant neoplasm of bladder, essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 was moderately cognitively impaired. Review of the wound evaluation dated 05/11/22, revealed Resident #56 had a stage three pressure wound to the coccyx measuring 2 centimeters (cm) by 0.5 cm by 0.3 cm. Review of physician order dated 05/12/22 revealed prescribed wound care to coccyx; cleanse with wound cleanser and pat dry; apply triad cream and a foam dressing every day shift every Monday, Wednesday, Friday, and as needed. Review of the Treatment Administrative Record (TAR) for May 2022, revealed Resident #56's coccyx wound dressing was last applied on Friday, 05/13/22, as ordered. The treatment was not completed on Monday, 05/16/22. Interview on 05/16/22 at 11:45 A.M. Resident #56 verified he had a coccyx wound and reported there was no dressing applied. Interview on 05/16/22 at 12:33 P.M. with Licensed Practical Nurse (LPN) #392 verified Resident #56 had a wound treatment order for a coccyx wound. LPN #392 reported she had not yet done Resident #56's wound treatment on 05/16/22. LPN #392 and surveyor entered Resident #56's room. LPN #392 checked Resident #56's coccyx wound and verified no wound treatment was applied. LPN #392 reported she was unaware of when Resident #56's coccyx wound treatment was removed and/or fell off. Further review of Resident #56's medical record revealed no documentation providing rationale as to why Resident #56's wound treatment was removed and/or if the wound treatment fell off. Review of wound evaluation dated 05/17/22 revealed the wound was resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 3 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to change/date oxygen supplies. This affected two residents (#1 and #56) out of two residents reviewed for respiratory care. The facility identified five additional residents (#2, #19, #14, #264, and #266) receiving supplemental oxygen. The facility census was 72. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #56 was admitted on [DATE]. Diagnosis includes sepsis, emphysema,chronic obstructive pulmonary disease, acute respiratory failure, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 was moderately cognitively impaired. Review of physician order dated 05/12/22, revealed an order to change oxygen tubing every Wednesday during night shift. Observation on 05/16/22 at 11:31 A.M. revealed Resident #56 had oxygen applied and the oxygen tubing was not dated. Interview on 05/16/22 at 12:32 P.M. Licensed Practical Nurse (LPN) #392 verified Resident #56's oxygen tubing was not dated and did not know when it was last changed. 2. Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnosis included acute on chronic diastolic (congestive) heart failure, anemia, chronic atrial fibrillation, chronic ischemic heart disease, chronic obstructive pulmonary disease, essential (primary) hypertension, acute kidney failure, obstructive sleep apnea, presence of cardiac pacemaker, shortness of breath, and chronic respiratory failure with hypoxia. Review of the MDS assessment dated [DATE], revealed the resident was moderately cognitively impaired. Review of the physician order dated 05/03/22, revealed an order to change oxygen tubing every Tuesday during night shift. Observation on 05/16/22 at 9:16 A.M. revealed Resident #1 had oxygen applied and the oxygen tubing was not dated. Interview on 05/16/22 at 12:32 P.M. LPN #392 verified Resident #1's oxygen tubing was not dated and did not know when it was last changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 4 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

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 medical record review, observation, staff interview, and review of facility policy, the facility failed to administer medications in a timely manner and prevent significant medication errors. This affected two residents (#24 and #262) out of seven residents reviewed for medications. The facility census was 72. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnosis included fracture of second lumbar vertebra, neuromuscular dysfunction of bladder, depression, type two diabetes mellitus, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, chronic pain, anxiety disorder, osteoarthritis, essential (primary) hypertension, and irritable bowel syndrome without diarrhea. Interview on 05/16/22 at 2:33 P.M. Resident #25 reported she had not received her morning medications on 05/16/22. Resident #25 reported she was up for breakfast and had therapy that morning. Resident #25 reported she did take a nap at some point, but did not recall any staff attempting to wake her up or administer medications. Interview on 05/16/22 at 2:35 P.M. Licensed Practical Nurse (LPN) #392 verified Resident #25 had not yet received her morning medication and she was just preparing the medication. Review of the Medication Administration Record (MAR), for May 2022, revealed 8:00 A.M. medications included: Incruse Ellipta Aerosol Powder Breath Activated 62.5 micrograms (MCG), Losartan Potassium Tablet 50 milligram (MG), Multivitamin Tablet, Omeprazole Tablet Delayed Release 20 MG, Tamsulosin HCI Capsule 0.4 MG, Vitamin B + C Complex Tablet, Ensure, Lorazepam Tablet 0.5 MG, Metoprolol Tartrate Tablet 25 MG, Gabapentin Capsule 100 MG, Hydralazine HCI tablet 25 MG, Sodium Chloride Tablet 1 gram, and Tylenol Extra Strength 500 MG. Review of the progress note dated 05/16/22 at 2:44 P.M. revealed the physician was aware Resident #24 did not receive 8:00 A.M. medications timely. The nurse attempted to arouse the resident earlier in the shift, but was unsuccessful. The physician approved for 8:00 A.M. medications to be administered at 2:30 P.M. and to not administer 12:00 P.M. medications due to repeat medications. Ultimately, Resident #24 missed 12:00 P.M. medications. Review of therapy times on 05/16/22, revealed Resident #24 received occupational therapy from 10:20 A.M. to 10:55 A.M., indicating Resident #24 was awake. Review of meal documentation, dated 05/16/22, revealed Resident #25 ate approximately 26-50% of breakfast at 8:00 A.M. and 51%-75% of lunch at 12:00 P.M., indicating Resident #25 was awake. Interview on 05/17/22 at 1:48 P.M. LPN #392 verified she had only tried twice on 05/16/22 to wake Resident #25 for her morning medications. LPN #392 reported it was a very busy day and she could not get morning medication passed on time. 2. Review of the medical record revealed Resident #262 was admitted on [DATE]. Diagnosis included COVID-19, muscle weakness, Parkinson's disease, unspecified fall, essential (primary) hypertension, and atelectasis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 5 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 05/16/22, revealed Resident #262's family reported concerns regarding the resident's medication, Sinemet (Parkinson's medication). If the medication was not provided between 7:00 A.M. and 8:00 A.M. in the morning, the resident's toes would curl under and her feet would begin to shake. Review of the MAR dated 05/2022, revealed 8:00 A.M. medications included, Cozaar Tablet 25 MG, Carbidopa-Levodopa tablet 25-100 mg, Famotidine Tablet 10 MG, and Ropinirole HCI Tablet 0.25 MG. Interview on 05/17/22 at 10:56 A.M. Resident #262 reported she had not received morning medications prescribed at 8:00 A.M. until 10:30 A.M. on 05/16/22. Interview on 05/17/22 at 1:53 P.M. with LPN #392 revealed Resident #262's family called 05/16/22 at approximately 10:30 A.M. upset because Resident #262 had not yet received morning medications. LPN #392 reported she had a busy day on 05/16/22 and could not get medications passed timely. Review of the facility undated policy, Administrating Medications, revealed medications must be administered within one hour of their prescribed time, unless otherwise specified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 6 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 review of facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect 70 residents who received food from the kitchen. The facility census was 72. Observations on 05/16/22 from 8:07 A.M. to 8:20 A.M. of the kitchen, with Dietary Manager #394 present, revealed the following food items located in the refrigerator were not dated: a bowl of salsa, a bag of lettuce, a bin of chopped onions, one large tub of sliced cheese, zip locked bag with 10 cooked hamburger patties, a zip locked back with one pound of deli ham, a bin of chopped pears, and a zip lock back of 12 hard boiled eggs. Dietary Manager #394 verified undated food items. Review of facility undated policy titled, Receiving and Storage Policy and Procedure, revealed food would be stored in its original packaging as long as the packaging was clean, dry, and intact. Food that was repackaged would be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container would be labeled with name of the contents and dated with the date it was transferred to the new container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 7 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure proper personal protective equipment (PPE) was worn when providing care to new admission residents who were unvaccinated for Coronavirus 2019 (COVID-19). This affected two residents (#264 and #265) of four residents reviewed for COVID-19 isolation precautions. The census was 72. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #265 was initially admitted on [DATE] and readmitted on [DATE]. Diagnosis included sepsis, anemia, acute kidney failure, type two diabetes mellitus without complications, essential (primary) hypertension, hypotension, and major depressive disorder. Review of Resident #265's vaccination history revealed the resident refused the COVID-19 vaccination and had no documentation of ever receiving a COVID-19 vaccine. Observation on 05/18/22 at 2:33 P.M. revealed Licensed Practical Nurse (LPN) #380 entering Resident #265's room wearing a surgical mask, gown, and face shield. LPN #380 was not wearing an N95 mask. Resident #265 was on quarantine due to readmitting to the facility and was unvaccinated for COVID-19. Interview on 05/18/22 at 4:52 P.M. LPN #380 verified she did not wear an N95 mask when entering Resident #265's resident room. 2. Review of the medical record revealed Resident #264 was admitted on [DATE]. Diagnosis included end stage renal disease, chronic obstructive pulmonary disease, acute and chronic respiratory failure, acute pulmonary edema, essential (primary) hypertension, hyperlipidemia, heart failure, hypothyroidism, and anemia. Review of Resident #264's vaccination history revealed the resident refused the COVID-19 vaccination and had no documentation of ever receiving a COVID-19 vaccine. Observation on 5/18/22 at 3:37 P.M. revealed LPN #391 donned (put on) a gown, gloves, surgical mask, an N95 mask over the surgical mask, and face shield to administer Resident #264's medications. Resident #264 was on quarantine due to recently admitting to the facility and was unvaccinated for COVID-19. Interview on 05/18/22 at 3:38 P.M. LPN #391 verified she placed an N95 mask over her surgical mask when entering Resident #264's room. Review of facility undated policy titled, COVID-19 Use of Personal Protective Equipment, revealed health care professionals providing care for residents confirmed or suspected of SARS-CoV-2 (COVID-19) should wear full personal protective equipment including a N95 or equivalent or high level respirator, eye protection, gown, and gloves. Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/22, revealed residents who were not up to date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 8 of 9 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 365900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380 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)

F 0880 with recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365900 If continuation sheet Page 9 of 9