Versailles Rehabilitation and Health Care Center

Inspectors wroteBased on medical record review, staff interview, Hospice provider interview, review of facility incident investigation report, review of Hospice documentation, review of facility self reported incidents (SRI's) and policy review, the facility failed to report an injury of unknown origin to the State Agency. This affected one (#85) resident out of three reviewed for injuries. The facility census was 84.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, staff and physician interviews, the facility failed to ensure a resident's physician progress notes accurately reflected an evaluation of the resident's condition and program of care. This affected one (#43) of three residents reviewed for physician services. The facility census was 76.

Inspectors wroteBased on medical record review, review of arbitration agreements and staff and resident interviews, the facility failed to ensure facility staff knew a residents' cognitive status and ability to understand before having the resident sign an arbitration agreement. This affected three (#29, #60, and #66) of three residents reviewed for arbitration agreements. The census was 76.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed ensure Hospice provider contracts, plans of care, and/or communication binders were available at the facility. This affected (#60) of one reviewed for Hospice. The census was 76.

Inspectors wroteBased on review of personnel files, staff interview, and review of facility policy, the facility failed to ensure new employees were screened against the state nurse aide registry for potential concerns with abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This affected three (#381, #384 and #396) of six personnel records reviewed. This had the potential to affect all 76 residents residing in the facility. The census was 76.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility failed to ensure the facility was free from foul odors. This affected two (Resident #43 and #44) of two residents reviewed for concerns with foul odors. The facility census was 87.

Inspectors wroteBased on resident and staff interviews, record review, and policy review, the facility failed to protect the residents and prevent further potential sexual abuse while the investigation was in process. This affected two (Residents #19 and #76) of two residents reviewed for abuse. The facility census was 87.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, policy review and staff interview, the facility failed to ensure medications were administered per physician orders. This affected one (#2) of 3 residents reviewed for medication administration. The current census is 76.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to keep accurate records regarding peritoneal dialysis treatments. This affected one (#79) of three residents reviewed for dialysis. The facility census was 70.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect 70 residents who received food from the kitchen. The facility census was 72. Observations on 05/16/22 from 8:07 A.M. to 8:20 A.M. of the kitchen, with Dietary Manager #394 present, revealed the following food items located in the refrigerator were not dated: a bowl of salsa, a bag of lettuce, a bin of chopped onions, one large tub of sliced cheese, zip locked bag with 10 cooked hamburger patties, a zip locked back with one pound of deli ham, a bin of chopped pears, and a zip lock back of 12 hard boiled eggs. Dietary Manager #394 verified undated food items. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a significant change assessment was completed in a timely manner for a resident. This affected one resident (#16) out of 18 residents reviewed for assessments. The facility census was 72.

Inspectors wroteBased on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to ensure wound dressings were applied and completed according to physician orders. This affected two residents (#9 and #56) out of ten residents reviewed for wound care. The facility census was 72.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to change/date oxygen supplies. This affected two residents (#1 and #56) out of two residents reviewed for respiratory care. The facility identified five additional residents (#2, #19, #14, #264, and #266) receiving supplemental oxygen. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to administer medications in a timely manner and prevent significant medication errors. This affected two residents (#24 and #262) out of seven residents reviewed for medications. The facility census was 72.

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure proper personal protective equipment (PPE) was worn when providing care to new admission residents who were unvaccinated for Coronavirus 2019 (COVID-19). This affected two residents (#264 and #265) of four residents reviewed for COVID-19 isolation precautions. The census was 72.

Inspectors wroteBased on medical record review, review of a dietary communication form and staff interview, the facility failed to ensure a cognitively impaired resident was supervised during meal service when being provided with hot liquids. This resulted in actual harm for one resident (#49) when she suffered burns from being served hot liquids on two separate occasions. In addition, the facility failed to ensure a staff member used a gait belt while transferring a second resident (#25) resulting in an avoidable fall that did not result in injury. This affected two (#49 and #25) of three residents reviewed for accidents. The census was 72.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to ensure routine showers were completed as per the resident's schedule/choice. This affected one (#6) of one residents reviewed for showers. The census was 72.

Inspectors wroteBased on medical record review, review of resident funds and staff interview, the facility failed to ensure one resident's funds were sent back to the state within 30 days of the resident's death. This affected one (#134) of six residents reviewed. The facility held funds for 45 residents. The census was 72.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident had a valid code status on file. This affected one (#28) of 24 residents reviewed for code status during the annual survey. The census was 72.