Versailles Rehab: Sexual Assault Between Residents - OH
The nursing assistant, identified in inspection records only as STNA #210, immediately separated the two residents and called for help. She did not leave them alone again.
Both residents had severe cognitive impairment. Both lived on a secured, locked unit. Neither could consent to what had happened.
That incident, investigated by federal inspectors who visited Versailles Rehabilitation and Health Care Center on August 28, 2025, sits at the center of a complaint inspection that found the facility out of compliance with its obligation to protect residents from sexual abuse. The complaint number assigned to the investigation is 2597903.
What makes the finding difficult to read past is where it happened. Not in a private room. Not in a corridor at night. In a common area, on a couch, in a space designed for shared use by residents and staff throughout the day.
The facility's administrator confirmed to inspectors that neither Resident #26, the male resident, nor Resident #90, the female resident, had ever shown sexually aggressive behavior before the incident. The administrator and the director of nursing both confirmed the cognitive impairment of each resident and acknowledged that neither was capable of consenting to a sexual encounter.
After the incident was discovered, the facility placed Resident #90 on one-on-one supervision, meaning a staff member was assigned to remain with her at all times. That supervision continued until she was discharged. The administrator told inspectors the facility had also taken steps that included notifying the police department, the families of both residents, and the physician.
STNA #210, interviewed by inspectors the afternoon of August 28 at 2:44 p.m., described what she saw and what she did in plain terms. She said she had been walking in the hallway when she observed the two residents in the common area. She separated them immediately and called for help. She confirmed that both residents had severely impaired cognition and could not have agreed to what was occurring.
She did not hesitate. She did not walk past. She acted.
But the question the inspection record leaves open is what conditions made the incident possible in the first place. A locked unit is designed to contain residents who cannot safely navigate the outside world on their own, residents whose cognition is impaired enough that they require a secured environment. It is also supposed to be a place where they are watched. Where the layout and the staffing together mean that two residents cannot end up in a prolonged, sexually explicit situation in a shared common room without anyone noticing until a nursing assistant happens to walk by.
The inspection report does not describe how long the two residents had been in that position before STNA #210 arrived. It does not say whether anyone else passed through or near the common area before she did. It does not detail what the staffing levels were on the unit that day, or whether any supervision protocols were in place before the incident that might have prevented it.
What the report does say is that the facility's own written abuse prevention policy, dated September 2021, states that residents have the right to be free from abuse, including sexual abuse, and that the administration is responsible for protecting residents from abuse by anyone, including other residents. The policy names other residents explicitly in its list of potential sources of harm.
The gap between that policy and what STNA #210 found on the couch is what the inspection is documenting.
Versailles Rehabilitation and Health Care Center is a nursing facility in a small Ohio town, roughly an hour north of Dayton. The inspection was a complaint inspection, meaning it was triggered by a report filed with the state, not a routine survey. Complaint inspections are initiated when someone, whether a staff member, a family member, or another resident, contacts authorities to report a specific concern.
Someone filed that complaint. The inspection record does not say who.
CMS, the federal agency that oversees nursing home compliance, assigned the deficiency a harm level of "minimal harm or potential for actual harm." That classification is a regulatory designation, not a moral one. The harm level affects how the violation is categorized and what enforcement consequences may follow. It does not describe what Resident #90 experienced.
Resident #90 was a woman with severe cognitive impairment living on a locked unit. She was, by the facility's own admission and the nursing assistant's direct observation, subjected to a sexual act she could not understand and could not refuse. She was placed on one-on-one supervision afterward and then discharged. The inspection report does not say where she went.
Resident #26 remained at the facility. The report does not describe what, if any, changes were made to his supervision or care plan after the incident.
The administrator's statement that neither resident had shown sexually aggressive behavior before is relevant to how the facility understood the risk landscape before that day. It is also, in a sense, the kind of statement that explains how something like this can happen in a place with a written policy against it. Facilities build their monitoring and supervision around known risks. When a resident has no prior history of a particular behavior, that behavior may not appear in the care plan as something to watch for. The couch in the common room is just the couch in the common room, until it isn't.
That is not an excuse. It is a description of how protective systems can fail residents who cannot protect themselves.
STNA #210 did what she was supposed to do. She saw something wrong, she intervened, she stayed, she called for help. The inspection record treats her response as appropriate. But her response was reactive. It happened after the fact, because she happened to be walking down that hallway at that moment.
Resident #90 could not call for help. She could not tell anyone what had happened to her. She could not describe it to her family, or to the physician who was notified, or to the police. She was on a locked unit precisely because her cognition was too impaired for her to navigate the world safely on her own.
The facility's policy says the administration will protect residents from abuse by anyone. The incident under investigation is the record of what happened when that protection was not in place.
The inspection was completed August 28, 2025. The complaint file number is 2597903.
Resident #90 has since been discharged. The report does not say to where.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Versailles Rehabilitation and Health Care Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
VERSAILLES REHABILITATION AND HEALTH CARE CENTER in VERSAILLES, OH was cited for violations during a health inspection on August 28, 2025.
The nursing assistant, identified in inspection records only as STNA #210, immediately separated the two residents and called for help.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.