Virgil Rehabilitation & Skilled Nursing Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

called the police, notified the Ombudsman, and CDPH when Resident 1 did not return after midnight. The DON stated anything could happen to Resident 1 while out on pass. The ADM stated Resident 1 could have gotten into an accident when Resident 1 did not return from out on pass. The ADM stated she (ADM) could not guarantee Resident 1 was safe after not returning to the facility. During an interview on 10/10/2025 at 12:02 PM with the ADM, the ADM stated the facility notified the police, Ombudsman, and CDPH on 10/8/2025 that Resident 1 did not return to the facility after going out on pass on 10/7/2025.

During a concurrent interview and record review on 10/10/2025 at 12:09 PM, the facility's fax confirmation sheets dated 10/8/2025 were reviewed with the ADM. The confirmation sheets indicated the facility sent a fax regarding Resident 1 not returning to the facility from out on pass on 10/7/2025 to the CDPH on 10/8/2025 at 3:39 PM and to the Ombudsman on 10/8/2025 at 3:48 PM. The ADM stated the fax confirmations sheets were proof of when the facility notified CDPH and the Ombudsman. During a review of

the facility's P&P titled Elopement, dated 1/2025 was reviewed. The P&P indicated if a resident (in general) could not be located within 15 minutes, the police had to be notified, and the facility would need to document an unusual occurrence (something that happens that is not common or expected) and report the incident to CDPH.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Virgil Rehabilitation & Skilled Nursing Center

975 North Virgil Avenue Los Angeles, CA 90029

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

verified that Resident 1 did not have a care plan for out on pass. RN 1 stated if the facility did not follow the policy for out on pass, the facility would not be able to assess Resident 1's safety and the IDT would need to determine Resident 1's ability to go out on pass. During an interview on 10/9/2025 at 3:44 PM with the Director of Nursing (DON), the DON stated that since there was not an out on pass care plan the facility would not know when Resident 1 was supposed to return. During an interview on 10/10/2025 at 10:45 AM with the Administrator (ADM), the ADM stated Resident 1's going out on pass should have been care planned. During a review of the facility's policy and procedures (P&P) titled, Out on Pass Policy and Procedures, dated 4/2024, indicated, it is the policy of the facility to meet resident's physical and psychosocial needs to go out on pass. The facility will make reasonable efforts to ensure the residents' safety and uphold resident rights. The P&P indicated when residents request to go out on pass, the IDT team will assess the resident's ability to participate in activities outside the facility. During a review of the facility's policy and procedures (P&P) titled, Care Plans - Comprehensive, dated 1/2025, indicated, the Care Planning/IDT team, with the resident and/or his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The IDT team documents the Resident Assessment Protocol (RAP - a problem-oriented framework used in nursing homes to guide additional assessment after an initial evaluation, based on specific triggered conditions) summary sheet and/or record in the clinical record: the resident's status, the team's rational for deciding whether to proceed with care planning, and evidence the team considered the development of care planning interventions for all RAP's triggered by the MDS.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Virgil Rehabilitation & Skilled Nursing Center

975 North Virgil Avenue Los Angeles, CA 90029

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and ability to take medications. The policy indicated The Attending Physician's order should indicate whether the resident needs to be accompanied by a responsible person while out on pass. The resident 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. During a review of the facility's P&P titled Physician orders and Telephone Orders with a review date of 1/2025, the policy indicated All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Virgil Rehabilitation & Skilled Nursing Center

975 North Virgil Avenue Los Angeles, CA 90029

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

leaving the facility on 10/7/2025. The DON stated anything could happen to Resident 1 while out on pass.

The ADM stated Resident 1 could have gotten into an accident. The ADM stated she (ADM) could not guarantee Resident 1 was safe after not returning to the facility. During an interview on 10/10/2025 at 11:46 AM with RN 1, RN 1 stated he was not sure what the facility's policy for going out on pass was. RN 1 stated

the facility allowed residents (in general) to go out on leave independently (by themselves). RN 1 stated he placed the order may go out on pass on 10/1/2025 for Resident 1. RN 1 stated the order he placed for may go out on pass for Resident 1 was not clear. RN 1 stated he (RN 1) did not clarify the may go out on pass order, the order was vague and put Resident 1 at jeopardy (risk) because there was no agreed upon time for Resident 1 to return to the facility after going out on pass. RN 1 stated the facility did not follow their out

on pass policy because the facility did not conduct an IDT meeting before allowing Resident 1 to go out on pass by himself. During a telephone interview on 10/10/2025 at 11:13 AM with the Hospice Doctor (HD),

the HD stated he was the Medical Director for Resident 1's hospice and was Resident 1's hospice doctor.

The HD stated he could not recall 100 % giving the order for Resident 1 to go out on pass. The HD stated Resident 1 had 6 months to live due to heart failure issues. The HD stated he (HD) was not aware Resident 1 had an out on pass order and would not have allowed Resident 1 to go out independently (by himself) and should have been accompanied by a responsible party (the person responsible for Resident 1). The HD stated the facility did not inform him (HD) Resident 1 had a car or could drive himself. The HD stated he did not know Resident 1 was independent. The HD stated the facility did not invite HD to participate in an IDT meeting. The HD stated Resident 1 should not have been allowed to be out on pass for longer than four hours and should have gone out with a responsible party. The HD stated he would never place an order for out on pass without a specified time for return. During a follow up telephone interview on 10/10/2025 at 11:22 AM with the HD, the HD called to say Resident 1 was supposed to be out on pass with a family member. During a review of the facility's P&P titled Out on Pass Policy and Procedure with an update date of 4/2024, the policy indicated When a resident requests to go out on pass, the interdisciplinary Team (IDT) will assess the resident's ability to participate in activities outside the Facility, while taking into consideration

the resident's decision-making capacity, physical disabilities, and ability to take medications. The IDT assessment will be documented in the IDT notes. The policy indicated The Attending Physician and Psychiatrist (if applicable) will review the IDT's assessment and evaluate the resident's ability to participate

in activities outside the Facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications. The policy indicated The Attending Physician's order should indicate whether the resident needs to be accompanied by a responsible person while out on pass.

The resident 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. During a review of the facility's P&P titled Physician orders and Telephone Orders with a review date of 1/2025, the policy indicated All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order.

Event ID:

Facility ID:

If continuation sheet