Health inspection·May 29, 2024

F 0697 Provide safe, appropriate pain management 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, family member interview, and staff interview, the facility failed to assess for pain, administer medication for pain, and document effectiveness of the pain control interventions for one resident. This affected one (#1) of three residents reviewed for pain management. The current census is 81. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 04/10/24, transferred to the hospital on [DATE], returned to the facility on [DATE], and passed at the facility with hospice services on 05/06/24. Diagnoses for Resident #1 included: urinary tract infection, alcoholic cirrhosis of liver, obesity, cellulitis, and altered mental status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a two-person assist for Activities of Daily (ADL). Review of Resident #1's physician ordered medications revealed on 04/10/24, the resident was ordered to receive Acetaminophen 500 milligrams (mg) every 8 hours for pain and Hydrocodone 5/325 milligrams (mg) 1 tablet every 12 hours as needed for pain. On 04/29/24, the physician ordered Morphine Sulfate oral solution 100 mg/milliliter (ml), 0.25 ml, 0.5 ml, and 1 ml every 1 hour as needed for pain. Review of Resident #1's Medication Administration Record (MAR) dated April 2024 revealed on 04/16/24 Resident #1 was not administered any as needed pain medication. Per the MAR the resident did receive the Acetaminophen 500 mg as prescribed. The pain level was documented on the MAR as an '8' at 8:00 A.M. On 04/16/24, at 4:00 P.M. the pain level was still present at a '5'. On 04/29/24, the resident was not administered any scheduled or as needed pain medications. Further review of the April 2024 MAR revealed on 04/28/24, the nurse documented the pain level as a '7' pain level on the nightshift and on 04/29/24 the nurse documented a '7' pain level on the dayshift. No as needed pain medication was administered per the MAR for the 04/28/24 and 04/29/24 recorded pain assessments. Review of the nursing assessments dated 04/28/24 and 04/29/24 revealed the nurse documented the pain levels as '0'. Review of the hospice progress notes dated 04/28/24 and 04/29/24 revealed no pain level was addressed in the notes. Review of the nursing assessments dated 05/03/24 revealed the nurse documented the pain level as '0'. Review of Resident #1's MAR dated May 2024 revealed one dose of Hydrocodone 5/325 mg orally was (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 05/29/2024 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)