The violation came to light during a federal complaint investigation completed November 20, when inspectors discovered the facility had no "out on pass" care plan for Resident 1, despite the person regularly leaving the grounds.
RN 1 told inspectors that without following the facility's own policy for out-on-pass procedures, staff couldn't assess the resident's safety. The interdisciplinary team would need to determine the resident's ability to go out on pass, the nurse explained.
The Director of Nursing confirmed the problem during an October 9 interview. Since there was no out-on-pass care plan, the facility wouldn't know when Resident 1 was supposed to return, the DON stated.
A day later, the Administrator acknowledged the failure. Resident 1's going out on pass should have been care planned, the ADM told inspectors.
The facility's own policies, reviewed during the inspection, spelled out exactly what should have happened. The "Out on Pass Policy and Procedures," dated April 2024, stated it was facility policy to meet residents' physical and psychosocial needs to go out on pass while making reasonable efforts to ensure residents' safety and uphold resident rights.
When residents request to go out on pass, the policy indicated, the interdisciplinary team will assess the resident's ability to participate in activities outside the facility.
A separate policy on comprehensive care plans, dated January 2025, required the care planning team to work with residents and their families to develop and maintain comprehensive care plans identifying the highest level of functioning each resident could be expected to attain.
The policy required the interdisciplinary team to document assessment summaries and record in the clinical record the resident's status, the team's rationale for care planning decisions, and evidence the team considered developing care planning interventions.
None of this happened for Resident 1.
The breakdown represents a fundamental failure in resident safety protocols. Without a proper assessment, staff couldn't evaluate whether the resident was cognitively and physically capable of safely leaving the facility. Without return times, staff couldn't know if something had gone wrong during an outing.
The facility's out-on-pass policy acknowledged the safety stakes involved. It committed to reasonable efforts to ensure residents' safety while allowing them the freedom to leave the grounds.
But policies mean nothing without implementation.
The violation occurred at a 99-bed facility on North Virgil Avenue that provides both rehabilitation and long-term care services. Federal inspectors classified the harm level as minimal, affecting few residents.
However, the case illustrates how even basic safety protocols can break down when facilities fail to follow their own written procedures. The interdisciplinary team that should have assessed Resident 1's capabilities never convened for that purpose.
Staff interviews revealed a clear understanding of what should have happened. The RN knew the facility needed to assess safety. The Director of Nursing understood they couldn't track return times without a care plan. The Administrator acknowledged the care planning requirement.
Yet none of them had ensured the proper procedures were followed.
The facility's comprehensive care planning policy emphasized working with residents and families to identify the highest functioning level each person could achieve. For someone wanting to leave the facility periodically, that assessment becomes crucial.
Can they navigate safely? Do they have cognitive impairments that could put them at risk? Do they understand how to return? Do they have reliable transportation? These questions require systematic evaluation, not ad hoc decisions.
The January 2025 care planning policy also required documentation of the team's rationale for care planning decisions. This creates an accountability trail, showing what factors the team considered and why they reached particular conclusions about a resident's capabilities.
For Resident 1, no such documentation existed.
The violation highlights how resident autonomy and safety must be balanced through proper assessment and planning. Residents have rights to leave facilities and participate in community activities. But those rights come with corresponding obligations for facilities to ensure reasonable safety measures.
Without knowing when Resident 1 was supposed to return, staff couldn't distinguish between a planned extended outing and a potential emergency. Without assessing the resident's capabilities, they couldn't identify risks that might require additional precautions or support.
The facility had written the policies correctly. Staff understood the requirements when questioned. But somewhere between policy and practice, the system failed for Resident 1.
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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