Health inspection·August 28, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews, review of a facility self reported incident (SRI), and policy review, the facility failed to ensure residents were free from sexual abuse. This affected two (#26 and #90) out of three residents reviewed for abuse. The facility census was 75. Findings include: Review of the medical record for Resident #26 revealed an admission date of 06/27/25 with medical diagnoses of dementia with psychotic disturbances, chronic obstructive pulmonary disease (COPD), and mood disorder. Review of an admission Minimum Data Set (MDS) assessment, dated 07/03/25, which indicated Resident #26 had severely impaired cognition and required supervision with toilet hygiene and was independent with bed mobility, transfers, and bed mobility. Review of a physician order dated 06/27/25 stated Resident #26 had a mental disorder with diagnosis of behavioral disturbances and met the criteria for placement on the Mental Health Unit (MHU) and would benefit from the structure and activity-based philosophy. Review of Resident #26's progress notes revealed a note dated 08/13/25 at 11:01 P.M. which stated Resident #26 was immediately separated from the other resident related to incident and resident assessment completed with no new skin impairments. Further review of the note revealed Resident #26 denied any pain and the physician, Administrator and Director of Nursing (DON) were notified. 2. Review of the medical record for Resident #90 revealed an admission date of 02/20/25 with medical diagnoses of dementia with agitation, Alzheimer's disease early onset, post traumatic stress disorder, and history of physical and sexual abuse. Review of the medical record revealed Resident #90 discharged from the facility to another facility on 08/15/25. Review of a quarterly MDS assessment, dated 05/29/25, indicated Resident #90 had severe cognitive impairment and required partial/moderate assistance with bathing and toilet hygiene and was independent with transfers and bed mobility. Review of a physician order dated 05/06/25 stated Resident #90 had a mental health disorder with diagnosis of behavioral disturbances and met the criteria for placement on the MHU and wound benefit from the structure and activity-based care philosophy. Review of Resident #90's progress notes revealed a note dated 08/13/25 at 11:01 P.M. which stated Resident #90 was immediately separated from the other resident related to the incident. The note stated Resident #90 was assessed and no new skin impairments were noted, and Resident #90 did not complain of pain. The note stated the Administrator and DON were noted and a message was left for family. Further review of progress note dated 08/13/25 at 11:45 P.M stated the police department was at the facility to investigate the incident. Review of a facility SRI, dated 08/13/25, stated Residents #90 and #26 were both residents on the MHU and were observed in a sexual encounter. Review of the FRI revealed State Tested Nursing Assistant (STNA) #210 observed Resident #26 and #90 sitting in a common area and Resident #90 was observed to be sitting on the couch with Resident #26 standing in front of her and his penis was in her mouth. The SRI indicated the residents were immediately separated and Resident #90 was put on one-on-one supervision. The SRI stated both resident families, the physician, and police (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 08/28/2025 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)