Health inspection·February 19, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations and staff interviews, the facility failed to ensure a medications were administered as ordered resulting in two medication errors out of 31 opportunities or a 6.45 percent (%) medication error rate. This affected one (#13) of three residents observed for medication administration. Facility census was 93. Residents Affected - Few Findings include: Review of medical record for Resident #13 revealed admission date of 02/13/25. Diagnoses include fracture of the ninth and tenth thoracic (T-9, T-10) vertebrae, spinal fusion, and surgical aftercare following surgery on the nervous system. Review of Resident #13's admission Minimum Data Set (MDS) revealed the assessment was not completed at the time of the survey. Review of Resident #13's care plan revealed a care plan for impaired skin integrity as evidenced by surgical incision to midline spine, left and right midline spine with interventions which included wound evaluation, dietician consult and medications as ordered. Review of Resident #13's physician orders revealed an order for Magnesium 250 milligrams (mg) give two capsules one time daily with a start date of 02/14/25 status was listed as on hand. Further review revealed an order for Hibiclens external four % solution apply to incision on back topically two times daily with a start date of 02/13/25 status was listed as on order. Review of Resident #13's February 2025 Medication Administration (MAR) revealed an order for Hibeclens external solution four % twice daily which was scheduled at 7:00 A.M. and again between 7:00 P.M. to 11:00 P.M. Further review of the MAR revealed there was a 9 documented at 7:00 A.M. on 02/14/25, 02/15/25, 02/18/25 and 7:00 P.M. to 11:00 P.M. on 02/13/25, 02/14/25, and on 02/15/25. Review of the chart code revealed a 9 was other/ see progress notes. Review of Resident #13's progress notes on 02/14/25, 02/15/25, 02/16/25 and 02/18/25 revealed Hibeclens external solution four % was not available. There was no note for 02/13/25 or 02/14/25. Observation on 02/18/25 at 10:28 A.M. of the medication pass for Resident #13 by Licensed Practical Nurse (LPN) #10 revealed Magnesium (supplement) 250 milligrams (mg) and Hibiclens (topical antiseptic/antibacterial agent) four % was not available for administration. LPN #10 verified the medications (Magnesium and Hibiclens) were not available at the time of the observation. Interview with the Director of Nursing (DON) on 02/18/25 at 4:12 P.M. revealed Magnesium 250 mg (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 02/19/2025 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)