Health inspection·May 8, 2025

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff and resident interviews, observation, and review of policy, the facility failed to ensure residents had orders and were assessed for secured units resulting in involuntary seclusion. This affected two (#60 and #180) of two residents reviewed for involuntary seclusion and had the potential to affect 13 additional residents (#3, #4, #5, #7, #17, #26, #32, #34, #35, #62, #68, #73, and #76) residing in the secured mental health unit (MHU) that did not orders for and were not assessed for admission to the secured MHU. The census was 76. Residents Affected - Some Findings include: 1. Review of Resident #60's medical record revealed an admission date of 01/26/24. Diagnoses listed included epilepsy, hypertension, anxiety, paranoid schizophrenia, and depression. Review of a significant change Minimum Data Set (MDS) revealed Resident #60 had severely impaired cognition and was receiving Hospice services. Further review of Resident #60's medical record revealed no order for admission to secured MHU. There was no documentation of any assessments being completed to ensure Resident #60 was appropriate for the secured MHU. Observations during the survey form 05/05/25 through 05/08/25 revealed Resident #60 resided in the MHU. Resident #60 was unable to be interviewed due to poor cognition. 2. Review of Resident #180's medical record revealed an admission date of 05/01/25. Diagnoses listed included alcohol dependence, post-traumatic stress disorder, anxiety disorder, major depressive disorder, hypertension, and obstructive sleep apnea. A MDS had not yet been completed for Resident #180. Review of progress notes revealed on 05/06/25 at 6:31 P.M. Resident #180 was assessed with a brief interview for mental status (BIMS) score of 15 (cognitively intact). Further review of Resident #180's medical record revealed no order for admission to secured MHU. There was no documentation of any assessments being completed to ensure Resident #60 was appropriate for the secured MHU. During an interview on 05/05/25 at 9:57 A.M. Resident #180 stated he was transferred from another facility into this facilities MHU because he had been caught drinking at the other facility. Resident (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 7 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 05/08/2025 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)