Health inspection·October 25, 2023

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the facility failed to keep accurate records regarding peritoneal dialysis treatments. This affected one (#79) of three residents reviewed for dialysis. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #79 revealed admission [DATE] with diagnoses including but not limited to breakdown (mechanical) of intraperitoneal dialysis catheter, morbid obesity, chronic kidney disease stage five, hyperkalemia, bilateral osteoarthritis of hip, depression, hyperlipidemia, coronary artery disease, fibromyalgia, anxiety, end stage renal disease, atrial fibrillation, hypertension, and dependence on renal dialysis. Review of Quarterly Minimum Data Set (MDS) assessment for Resident #79 dated 08/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. No behaviors noted. Resident #79 required limited to supervision of one for Activities of Daily Living (ADL's). Review of care plan for Resident #79 dated 08/25/23 revealed resident had impaired genitourinary status related to end stage renal disease and dialysis dependence. Peritoneal dialysis in house. Interventions included but not limited to consult with urologist/nephrologist as needed, dialysis orders as indicated, call if systolic blood pressure is greater than 170, weight greater than five pounds over target weight of 216 pounds, diet as ordered, elevate feet when sitting up in chair to help prevent dependent edema, encourage fluids as tolerated unless contraindicated, monitor for signs and symptoms of dehydration, labs/diagnostic testing as ordered, medications per physician orders, monitor and report changes in mental status, monitor and report signs or symptoms of urinary tract infection, monitor and report signs and symptoms of acute renal failure, monitor dialysis catheter to right abdomen for length, signs and symptoms of infection, or clogged with fibrin, administer heparin as ordered, gentamycin cream to catheter site, periodically check vital signs and lung sounds, report any significant abnormal findings, report signs and symptoms of urinary retention/insufficiency to physician, treatments as ordered, weights as ordered, and monitor dialysis access site and report to physician signs and symptoms of bleeding, infection, redness, swelling, local warmth, or tenderness. Review of monthly physician orders for Resident #79 revealed call dialysis if weight is five pounds over target weight (TW) of 212 pounds and/or elevated blood pressure for new orders for peritoneal dialysis (PD). Sliding scale: monitor signs and symptoms fluid overload/dehydration systolic blood pressure (SBP) 90-100 and weight two pounds below TW equals (=) two one and a half percent (1.5%) dextrose and dwell bag (purple) SBP 110-140 and weight at TW = one 1.5% and one two and a half percent (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: 365900 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 10/25/2023 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)