Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Versailles Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents were placed in a secured mental health unit without required physician orders or assessments to determine their appropriateness for this level of restriction, resulting in involuntary seclusion. Facility staff confirmed that no orders or assessments were completed for these or thirteen other residents in the unit, contrary to facility policy requiring such evaluations before placement.
A physician's progress notes for a resident on hospice care inaccurately documented ongoing diabetic monitoring and treatment, despite the absence of blood glucose orders, diabetic labs, or diabetic medications. The physician was unaware of the resident's hospice status and used a generic note for diabetic residents, while nursing staff did not communicate any concerns about blood sugar management.
Facility staff allowed three residents, including those with severe cognitive impairment and Alzheimer's disease, to sign binding arbitration agreements without assessing their ability to understand the documents. Staff confirmed that the electronic signature process applied signatures to all sections, including arbitration, regardless of resident capacity, and acknowledged the absence of a facility policy on arbitration agreements.
A resident with severe cognitive impairment and multiple medical conditions was receiving hospice care, but the facility did not have the required hospice provider agreement, plan of care, or communication binder available. Staff interviews confirmed the absence of these documents and hospice staff signature logs, which were only obtained after the issue was identified during the survey.
The facility did not screen new hires, including two LPNs and a Business Office Manager, against the state nurse aide registry for findings of abuse, neglect, exploitation, or misappropriation of resident property as required by policy. This lapse was confirmed through personnel file reviews and staff interviews.
A facility failed to administer medications as ordered, resulting in a 6.45% medication error rate. A resident with spinal surgery aftercare did not receive prescribed Magnesium and Hibiclens due to unavailability and staff unawareness of medication location. The DON confirmed the issues with medication availability and staff oversight.
The facility failed to maintain a homelike environment due to a persistent cannabis odor affecting two residents. Interviews and observations confirmed the odor originated from a resident's room, with staff acknowledging frequent complaints and attempts to mask the smell with air freshener.
The facility failed to protect two residents during an investigation of potential sexual abuse. A resident with severe cognitive impairment and another resident were found engaged in a sexual act. Despite the impaired resident stating the act was consensual, the facility did not implement one-on-one observations or take immediate protective measures. Staff were unsure of how to handle the situation, and the facility's abuse prevention policy was not followed.
The facility failed to provide appropriate pain management for a resident with multiple diagnoses, including alcoholic cirrhosis and altered mental status. Despite physician orders for pain medications, the resident's MAR showed inconsistencies in administering these medications and documenting pain levels and interventions. Interviews revealed that the resident was often agitated and unable to verbalize pain levels, and the family had requested pain medication, which was not administered because the resident could not ask for it. The DON confirmed the lack of documentation and administration of pain medications.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess and Obtain Orders for Secured Unit Placement Resulting in Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that residents placed in the secured mental health unit (MHU) had appropriate physician orders and assessments to justify their placement, resulting in involuntary seclusion. Specifically, two residents were found residing in the secured MHU without any documented orders or completed assessments to determine their appropriateness for this level of restriction. One resident had severely impaired cognition and was receiving hospice services, while the other was cognitively intact and reported feeling depressed and inappropriately placed in the secured unit. Both residents' records lacked evidence of the required admission process to the MHU. Interviews with facility staff, including the Director of Social Services, DON, and Administrator, confirmed that not only these two residents but also thirteen additional residents in the secured MHU did not have the necessary orders or assessments for their placement. Facility policy required the admissions team to screen and assess residents before placement in the behavioral unit, but this process was not followed. The facility's abuse prevention policy also stated that residents should be free from involuntary seclusion, which was not upheld in these cases.
Physician Progress Notes Failed to Reflect Resident's Actual Care and Condition
Penalty
Summary
A deficiency was identified when a physician's progress notes for a resident failed to accurately reflect an evaluation of the resident's condition and program of care. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes with unspecified complications, anxiety, and hypertension, was admitted to hospice care and had severely impaired cognition, requiring total assistance for daily activities. The care plan included interventions for terminal illness and end-of-life comfort measures. However, the physician's notes repeatedly referenced blood sugar monitoring and continuation of a diabetic treatment plan, despite the absence of any blood glucose orders, diabetic labs, or diabetic medications for the resident during the review period. Record review and staff interviews confirmed that no blood glucose checks or diabetic labs had been ordered or performed, and the resident was not receiving diabetic medications. The physician acknowledged that the progress notes were a generic statement used for diabetic residents and admitted to being unaware that the resident was on hospice services. The physician also stated that nursing staff had not communicated any concerns regarding the resident's blood sugars, and he had overlooked the hospice status noted on the resident list.
Failure to Assess Cognitive Status Before Signing Arbitration Agreements
Penalty
Summary
Facility staff failed to ensure that residents' cognitive status and ability to understand were assessed before having them sign binding arbitration agreements. Three residents with varying degrees of cognitive impairment, including severe cognitive impairment and diagnoses such as Alzheimer's disease, dementia, and schizophrenia, were found to have signed arbitration agreements. In one case, a resident with severely impaired cognition, who was also receiving hospice services and resided in a secure mental health unit, signed the agreement despite being unable to understand it. Staff confirmed that the electronic signature process automatically populated all signature sections, including the arbitration agreement, regardless of the resident's capacity to consent. Another resident, who was cognitively intact at the time of assessment but had a diagnosis of Alzheimer's disease and periods of confusion, expressed confusion about signing the arbitration agreement and did not recall doing so. This resident was moved to the memory care unit the day after signing. A third resident with severe cognitive impairment and Alzheimer's disease also signed the agreement. Interviews with facility staff, including the Administrator and Admissions Coordinator, confirmed that these residents should not have signed the arbitration agreements and that the facility lacked a policy regarding arbitration agreements.
Failure to Maintain Required Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure that required hospice provider contracts, plans of care, and communication binders were available for a resident receiving hospice services. Medical record review showed that a resident with multiple diagnoses, including epilepsy, hypertension, anxiety, paranoid schizophrenia, and depression, was admitted and had a physician order for hospice services due to intracranial hemorrhage. However, there was no documentation of the hospice provider agreement or plan of care in the resident's medical record. During the survey, staff interviews revealed that a hospice communication binder was not present in the facility for the resident, and there was no sign-in sheet for hospice staff visits. The RN confirmed the absence of the hospice provider agreement, plan of care, and staff signature logs, and stated that the hospice provider had been contacted to bring the necessary documents. The DON also confirmed that the hospice provider agreement and plan of care were not available in the facility until the day of the interview, and there were no hospice staff signature logs or communication binder present prior to that.
Failure to Screen New Employees Against State Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that new employees were screened against the state nurse aide registry for findings related to abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. This deficiency was identified through a review of personnel files, staff interviews, and facility policy, affecting three out of six personnel records reviewed. Specifically, two LPNs and a Business Office Manager were hired without being screened against the state nurse aide registry as required by facility policy. Interviews with Human Resources and the Administrator confirmed that these employees were not screened upon hire. The facility's policy mandates background checks and prohibits employment of individuals with findings of abuse, neglect, exploitation, or related disciplinary actions. At the time of the survey, all three employees were subsequently screened and no abuse concerns were found, but the initial failure to conduct the required checks constituted the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%, which is above the acceptable threshold of 5%. This error affected one resident who was observed for medication administration. The resident, who had been admitted with diagnoses including fractures of the thoracic vertebrae, spinal fusion, and surgical aftercare, had specific physician orders for Magnesium and Hibiclens. However, these medications were not available for administration during the survey period. The review of the resident's Medication Administration Record (MAR) and progress notes revealed that the Hibiclens solution was not available on multiple occasions, and the Magnesium tablets were not available in the prescribed dosage. Observations confirmed that the medications were not administered as they were not available, and staff interviews revealed a lack of awareness regarding the location of the Hibiclens solution. The Director of Nursing confirmed the unavailability of the Magnesium tablets in the prescribed dosage and the oversight regarding the Hibiclens solution.
Facility Fails to Address Persistent Cannabis Odor
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents by not addressing the persistent foul odor of cannabis in the hallways and rooms. This issue was identified through interviews with residents and staff, as well as direct observations. Resident #44 expressed concerns about the constant smell of cannabis in the hallway, while Resident #43 was worried about the strong odor entering her room from the adjacent room, fearing potential health implications. Both residents were affected by the odor, which was traced back to Resident #19's room. Staff interviews, including those with a registered nurse, a state-tested nursing assistant, and a licensed practical nurse, confirmed the presence of a strong cannabis-like odor emanating from Resident #19's room. Environmental services staff also acknowledged the frequent complaints from residents about the odor and their attempts to mitigate it by spraying air freshener in the hallways. Despite these efforts, the odor persisted, indicating a failure to effectively address the issue and maintain a homelike environment for the residents.
Failure to Protect Residents During Investigation of Potential Sexual Abuse
Penalty
Summary
The facility failed to protect residents and prevent potential sexual abuse during an investigation involving two residents. Resident #19, who was cognitively intact, and Resident #76, who had severe cognitive impairment due to Alzheimer's disease, were found engaged in a sexual act. Despite Resident #76's severe cognitive impairment, she stated to the ER physician that the act was consensual. However, the facility did not implement one-on-one observations for either resident during the investigation to ensure their safety. The incident was reported by a State tested Nursing Aide (STNA) who observed the act and informed the Licensed Practical Nurse (LPN). The STNA did not intervene immediately, and the LPN, unsure of how to proceed, sought assistance from another nurse. The Director of Nursing (DON) and the Regional Licensed Nursing Home Administrator (RLNHA) confirmed that not all staff interviews were completed, and the facility did not take immediate protective measures for the residents involved. The facility's policy on abuse prevention and intervention was not followed, as immediate steps to protect the residents were not taken. The policy required the facility to separate residents involved in altercations and take prompt action to remove residents from immediate harm. The failure to adhere to these procedures resulted in a deficiency in protecting the residents during the investigation process.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, as evidenced by the lack of pain assessment, administration of pain medication, and documentation of the effectiveness of pain control interventions. The resident, who had diagnoses including urinary tract infection, alcoholic cirrhosis of the liver, obesity, cellulitis, and altered mental status, was admitted to the facility, transferred to the hospital, and later returned to the facility where they passed with hospice services. Despite having physician orders for Acetaminophen, Hydrocodone, and Morphine Sulfate for pain management, the resident's Medication Administration Record (MAR) showed inconsistencies in administering these medications and documenting pain levels and interventions. For instance, on multiple occasions, the resident's pain levels were recorded as high, but no as-needed pain medication was administered, and non-pharmacological interventions were not documented for their outcomes. Interviews with the family member and the Director of Nursing (DON) revealed that the resident was often agitated and unable to verbalize pain levels, and the family had requested pain medication, which was not administered because the resident could not ask for it. The DON confirmed that nurses were documenting pain levels but not administering as-needed pain medications or documenting the effectiveness of the interventions. The family member also noted that the facility nurses did not provide appropriate pain control before the resident's passing. The deficiency was confirmed during the investigation for Complaint Number OH00153769.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 129 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Versailles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Green Rehabilitation And Healthcare Center | 9.3 mi | ★★★★★ | 1 | 0 |
| Rest Haven Nursing Home Inc | 9.7 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Greenville | 10.1 mi | ★★★★★ | 12 | 0 |
| Stillwater Skilled Nursing And Rehabilitation | 10.3 mi | ★★★★★ | 11 | 0 |
| Brethren Retirement Community | 11.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Versailles Rehabilitation And Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.