Versailles Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Versailles Rehabilitation and Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Mar 30, 2022

  Based on medical record review, staff and family interview, observations, review of facility electronic screening data, review of screening temperature logs, policy review, review of a glucometer manufacturer instructions, review of information the Centers of Disease Control (CDC) and review of information from Centers for Medicare and Medicaid Services (CMS), the facility failed to ensure all visitors were screened upon entrance to the facility for Coronavirus Disease 2019 (COVID-19) signs and symptoms. This had the potential to affect all 69 residents residing in the facility. The facility failed to appropriately disinfect a glucometer with the appropriate disinfectant after residents use. […]

• No harm, potential for more than minimal, patternF603May 8, 2025

  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. Findings include: 1. Review of Resident #60's medical record revealed an admission date of 01/26/24. […]

• No harm, potential for more than minimal, patternF812May 23, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF880Apr 8, 2021

  Based on medical record review, observation, staff interview and policy review, the facility failed to implement their droplet isolation policy to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected four (#16, #17, #24 and #38) of four sampled residents reviewed for infection control. Facility census was 65. Findings include: 1. Review of the medical record for Resident #16 revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview of Mental Status (BIMS) score was 10 out of 15 indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF609Jul 8, 2026

  Based 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. Findings include: Review of the medical record for Resident #85 revealed an admission date of [DATE] with medical diagnoses of cerebral atherosclerosis, diabetes mellitus, dementia with behavioral disturbances, schizophrenia, and heart failure. Review of the medical record indicated Resident #85 was on Hospice services and expired [DATE]. […]