Health inspection·January 5, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the facility failed to ensure medications were administered per physician orders. This affected one (#2) of 3 residents reviewed for medication administration. The current census is 76. Findings include: Review of Resident #2's medical record revealed an admission date of 12/01/23 and discharged home on [DATE]. Diagnoses for Resident #2 included: aftercare for orthopedic surgery, fracture of femur, hemiplegia, dysphagia, and weakness. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, pain, and was a one-person assist for Activities of Daily (ADL). Review of Resident #2's care plans dated 12/04/23 revealed a focus for risk of pain. Interventions include administering medications per physician order, monitoring for pain symptoms, offer non-pharmacological interventions, and therapy as needed. Review of Resident #2's physician orders dated 12/01/23 revealed Resident #2 was prescribed Ferrous Sulfate 325 milligrams (mg) one time a day, Hydrocodone- Acetaminophen 5-325 mg every 6 hours for pain, Spironolactone 25 mg daily for hypertension, Aspirin 81 mg every 12 hours for post op blood thinner, and Docusate Sodium 100 mg twice a day for constipation. Review of Resident #2's Medication Administration Record (MAR) dated December 2023 revealed on 12/02/24, Resident #2 did not receive the ordered Ferrous Sulfate, Spironolactone, Aspirin, and Docusate Sodium for the scheduled morning doses. Further review of Resident #2's MAR revealed the resident received the first dose of Hydrocodone pain medication on 12/02/23 at 8:48 P.M. Review of Resident #2's Narcotic records dated December 2023 revealed one dose of Hydrocodone had been removed from the emergency supply under Resident #2's name. On the narcotic sheet the nurse documented the resident had been given one dose of Hydrocodone on 12/02/23 at 12:20 A.M. No further documentation of the 12/02/23 at 12:20 A.M. administration was noted in the resident's records. Interview on 01/05/24 at 2:45 P.M., with the Administrator verified there was no documentation of Resident #2 receiving her ordered Ferrous Sulfate, Spironolactone, Aspirin, and Docusate Sodium for the scheduled morning doses. Per the Administrator there was one Hydrocodone dose removed from the emergency supply and administered to Resident #2 per the narcotic records. The Administrator verified there was no documentation in the resident's records regarding the administration of the 12/02/24 at (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: 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 01/05/2024 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)