Health inspection·January 25, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff and resident interviews, the facility failed to ensure suprapubic catheter care was completed and documented in the medical record. This affected three (#9, #14, #45) of three residents reviewed for catheter care. The facility census was 83. Findings include: 1. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to bipolar disorder, suicidal ideation's, neuromuscular dysfunction of bladder, anxiety, major depression, history of mental and behavioral disorders, and history of urinary tract infections. Review of the admission Minimum Data Set (MDS) assessment for Resident #45 revealed an intact cognition. Resident #45 is independently ambulatory, and requires set up assistance for eating, toileting, and transfers. Resident #45 has an indwelling urinary catheter. Review of the plan of care for Resident #45 revealed resident has a need for supra-pubic catheter. Interventions include monitor for signs and symptoms of urinary tract infections and report to physician, report signs of perineal redness, irritation skin excoriation to physician, change catheter and drainage system as indicated, keep tubing free of kinks and twists, maintain drainage bag below the bladder, privacy cover to drainage bag and catheter care as needed. Review of the physicians' orders for Resident #45 for the month of December 2023 were silent for catheter care. Review of the physicians' orders for Resident #45 for the month of January 2024 revealed an order dated 01/25/24 for suprapubic catheter care: wash with soap and water, pat dry every day as needed, may apply a T-sponge if needed and every day-on-day shift. Interview on 01/25/24 at 12:20 P.M. with Licensed Practical Nurse (LPN) #2 verified she added the order for the catheter care today at the direction of the corporate nurse. LPN #2 verified Resident #45 did not have physician orders for catheter care until 01/25/24. Interview on 01/25/24 at 12:50 P.M. with LPN #5 assigned to Resident #45 verified she did not complete catheter care for Resident #45 on 01/24/24 as there were not any orders for the task. Interview on 01/25/24 at 1:17 P.M. with State Tested Nursing Assistant (STNA) #3 assigned to (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 01/25/2024 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)