Resident 1 failed to return to Virgil Rehabilitation & Skilled Nursing Center on October 7, 2025, after leaving on what staff called an "out on pass" order. The nursing home's director of nursing told investigators that "anything could happen" to the resident while he was gone. The administrator said the resident "could have gotten into an accident" and that she "could not guarantee Resident 1 was safe after not returning to the facility."
RN 1 placed the pass order on October 1 without consulting the resident's hospice doctor or holding the required interdisciplinary team meeting. During an October 10 interview, RN 1 admitted the order he wrote was "not clear" and "vague." He said the unclear order "put Resident 1 at jeopardy because there was no agreed upon time for Resident 1 to return to the facility."
The hospice doctor said he never would have approved the independent pass.
"I could not recall 100% giving the order for Resident 1 to go out on pass," the hospice doctor told investigators by phone. The doctor, who served as medical director for the resident's hospice care, said the patient had terminal heart failure with six months to live.
The doctor was unaware the facility had issued any pass order. "I would not have allowed Resident 1 to go out independently and should have been accompanied by a responsible party," he said. The facility never told him the resident had a car or could drive himself.
"I did not know Resident 1 was independent," the doctor said.
The hospice doctor said nursing home staff never invited him to participate in an interdisciplinary team meeting about the pass request, as required by facility policy. He said the resident "should not have been allowed to be out on pass for longer than four hours and should have gone out with a responsible party."
"I would never place an order for out on pass without a specified time for return," the doctor told investigators.
In a follow-up call minutes later, the hospice doctor said the resident "was supposed to be out on pass with a family member."
RN 1 acknowledged the facility failed to follow its own policies. He told investigators the nursing home "did not conduct an IDT meeting before allowing Resident 1 to go out on pass by himself," as required by written procedures.
The facility's pass policy, updated in April 2024, requires the interdisciplinary team to assess residents requesting passes, considering "decision-making capacity, physical disabilities, and ability to take medications." The policy states that both the attending physician and psychiatrist must review the team's assessment.
The policy specifically requires the attending physician's order to "indicate whether the resident needs to be accompanied by a responsible person while out on pass." It states residents "must be accompanied by a responsible person when leaving the facility unless the attending physician determines that the resident is capable of being on an independent pass."
A separate facility policy on physician orders, reviewed in January 2025, requires all orders to be "specific and complete with all necessary details to carry out the prescribed order without any questions."
RN 1 told investigators he was "not sure what the facility's policy for going out on pass was," despite being responsible for issuing such orders. He said the facility generally allowed residents "to go out on leave independently by themselves."
The inspection report does not indicate when or how Resident 1 eventually returned to the facility, or what condition he was in upon return. Federal investigators classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The hospice patient's disappearance highlighted multiple breakdowns in the nursing home's pass procedures, from the vague initial order to the failure to include his medical team in safety planning. For a terminally ill resident with six months to live, those hours away from medical supervision carried risks his own doctor said he never would have accepted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Virgil Rehabilitation & Skilled Nursing Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
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