Health inspection·July 29, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely monitored (constant observation) to prevent a fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force). The facility was aware that Resident 1 was confused (is the inability to think as clearly or quickly as you normally do), legally blind (severe vision loss), at high risk for falls, at risk for elopement (leaving a facility unsupervised and unnoticed), restless (feeling uneasy, agitated, or unable to relax or stay still), and was unable to sit still. As a result, Resident 1 had a fall witnessed by Resident 2 (unidentified date and time) that resulted for Resident 1 to sustain a left hip fracture (broken bone). On 7/22/2025 at 11:30 PM, Resident 1 was transported to the General Acute Care Hospital (GACH) where Resident 1 was admitted and underwent a left femur (thighbone) intramedullary (inside of a bone) rodding (bones or bone fragments are repositioned into their normal positions) surgery with general anesthesia (a temporary loss of feeling and complete loss of awareness that feels like a very deep sleep).Findings: During a review of Resident 1's admission Record, the admission Record indicted the facility admitted Resident 1 on 5/15/2025 with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, dementia (a progressive state of decline in mental abilities), other abnormalities of gait (your pattern of walking) and mobility (the ability to move), abnormal posture (the way you hold your body), age-related osteoporosis (a condition in which bones become weak and brittle), vitamin D deficiency (when the body does not have enough vitamin D and primarily causes issues with your bones and muscles), and sensorineural hearing loss (when the inner ear or the nerve connecting the ear to the brain is damaged, making it hard to hear clearly) bilateral (both ears/sides). During a review of Resident 1's Fall Risk Assessment (a tool to figure out how likely someone is to fall, especially for older adults) dated 5/15/2025, the Fall Risk Assessment indicated Resident 1 was legally blind and at high risk for falls. The Fall Risk Assessment indicated Resident 1 was disoriented (confused) at all times to name, place, and time and had balance (being able to stay upright and/or steady) problems while standing and while walking. The Fall Risk Assessment indicated to provide frequent visual monitoring (monitor by watching) and to anticipate (expecting something to happen and often to prepare for it in advance) needs in a timely manner. During a review of Resident 1's Care Plan Report (a structured and individualized document that spells out how a facility will meet a resident's health or personal care needs), dated 5/15/2025, the Care Plan Report indicated Resident 1 was at risk for fall related to Alzheimer's, dementia, and legally blind. The Care Plan Report indicated the goal was to minimize (limit) the occurrence (something that happens or takes place) of falls and /or injury for Resident 1. The Care Plan Report indicated the nursing interventions (an action taken to prevent, treat, or manage a health problem) were to provide Resident 1 with a safe environment, bilateral (both sides) floor mat (cushioned pad you put on the floor next to a bed in Page 1 of 6 055157 055157 07/29/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Actual harm Residents Affected - Few case someone falls to reduce the chance of injury), keep the call light (a device used by a patient to signal his or her need for assistance) within Resident 1's reach and answer the call light promptly (with no delay), and place Resident 1's bed in the low position. During a review of Resident 1's Physical Therapy notes dated 5/15/2025, the Physical Therapy notes indicated Resident 1 needed maximum assistance (the individual receiving care can participate in a task or activity, but requires significant assistance from a caregiver or therapist, typically performing only 25% or less of the work according to healthcare resources) to walk 25 feet (take steps for a distance of 25 feet in a straight line). The Physical Therapy notes indicated Resident 1 had balance deficits (having trouble staying steady on your feet). During a review of Resident 1's Care Plan Report dated 5/16/2025, the Care Plan Report indicated Resident 1 was at risk for elopement risk as evidenced by impaired cognition (someone has difficulty with thinking, learning, remembering, or making decisions), memory impairment (problems with remembering things). The Care Plan Report indicated Resident 1 would ambulate (walk) with assistance, and used medication that could cause confusion and disorientation (lack of awareness). The Care Plan Report indicated the nursing intervention was to monitor Resident 1's location (whereabouts) every __ (blank) min (minute). The Care Plan Report indicated to document wandering (move about aimlessly or without any destination) behavior and attempted diversional interventions (refers to the use of recreational and leisure activities to help patients cope with their medical conditions) in behavior log. The Care Plan Report indicated the nursing intervention was to provide Resident 1 with assistance during ambulation (the ability to walk or move from place to place). The Care Plan Report indicated the goal was to maintain Resident 1's safety. During a review of Resident 1's Interdisciplinary Team Conference Record (IDT - refers to a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care) notes dated 5/16/2025, the IDT Conference Record indicated Resident 1 needed maximum assistance with activities of daily living (ADLs basic self-care tasks needed to take care of oneself), was a fall risk, and was educated to use call lights. During a review of Resident 1's Order Summary Report dated 5/16/2025, indicated for Resident 1 to have bilateral floor mats. During a review of Resident 1's History and Physical (H&P - comprehensive document that records a resident's medical history and a detailed physical examination performed by a health care professional) dated 5/17/2025, the H&P indicated Resident 1 had fluctuating (changed frequently) capacity (person's ability to understand information and make decisions can change from day to day, or even hour to hour) to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/21/2025, the MDS Resident 1 had severe cognitive (reasoning) impairment. The MDS indicated Resident 1 needed substantial (at lot)/maximal (maximum) assistance with toileting (using the toilet). The MDS indicated Resident 1 was dependent (someone does all the effort) for showering/bathing. The MDS indicated Resident 1 needed substantial (extensive)/maximal assistance to walk ten feet (a unit of measure) to go from a sitting to standing position, and to transfer from chair/bed to chair. The MDS indicated Resident 1 needed partial/moderate assistance to go from sitting to lying position and to go from lying to sitting on the side of the bed. The MDS indicated Resident 1 did not have a fall prior to admission. During a review of Resident 1's Progress Notes dated 7/15/2025 at 11:44 PM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another (unidentified), standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to sit still, unable to calm herself, disoriented and Resident 1 wanted to walk outside her (Resident 1's) room and unable to determine the time. During a review of Resident 1's Order Summary review dated 7/15/2025, indicated to monitor Resident 1 for restlessness/inability to sleep every shift. 055157 Page 2 of 6 055157 07/29/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's Progress Notes dated 7/17/2025 at 7:14 AM, the Progress Notes indicated Resident 1 was noted to be restless, going from one bed to another (unidentified), standing and trying to walk by herself in the middle of the night. The Progress Notes indicated Resident 1 was unable to sit still, unable to calm herself, disoriented, and Resident 1 wanted to walk outside her (Resident 1's) room and unable to determine time (documented the same as the Progress Notes dated 7/15/2025 at 11:44 PM). During a review of Resident 1's Medication Administration Record dated 7/17/2025 indicated Resident 1 did not have behaviors related to anxiety (nervousness) manifested by sleeplessness on all three shifts.During a review of Resident 1's Change in Condition (Situation Background Appearance Review, SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/22/2025 at 11:45 PM, the SBAR indicated Resident 1 complained of left hip pain, left knee pain, and left foot pain (pain levels unidentified). The SBAR indicated Resident 1 had a left hip x-ray (a medical scan to get pictures of the inside of your body) that showed a fracture (broken bone) of the acetabulum (a cup-shaped socket in the pelvis that forms the hip joint) and was transferred to the ED (emergency department). During a review of Resident 1's GACH Clinical Notes dated 7/26/2025, the Clinical Notes indicated Resident 1 had a mechanical fall (a type of fall that occurs due to an external, physical factor rather than an underlying medical condition) and sustained a left hip intertrochanteric fracture (refers to a break in the upper part of the thigh bone [femur]. The Clinical Notes indicated Resident 1 underwent under general anesthesia and had a left femur intramedullary rodding surgery. During a review of the facility's Summary of Investigation report dated 7/27/2025, the Summary of investigation report indicated Resident 2 could not recall the date when she (Resident 2) saw and witnessed Resident 1 fall from the bed to the floor. The Summary of Investigation report indicated the facility concluded Resident 1 had a fall witnessed by Resident 2. During an interview on 7/28/2025 at 11:15 AM with the Director of Nursing (DON) and the facility's Administrator (ADM), the DON and ADM stated Resident 1 was currently in the GACH. The DON and ADM stated Resident 1's bed was on hold and the facility would accept Resident 1 back once stable for discharge from the GACH. During an interview on 7/28/2025 at 11:54 AM with the General Acute Care Hospital Registered Nurse (GACHRN), the GACHRN stated Resident 1 was still in the general acute care hospital. The GACHRN stated Resident 1 had a left femur intermedullary rodding. The GACHRN stated Resident 1 was confused, and unable to be interviewed. The GACHRN stated Resident 1 would be discharging from the GACH back to the skilled nursing facility on 7/28/2025. During an interview on 7/28/2025 at 12:51 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA1) was familiar with Resident 1. CNA 1 stated Resident 1 was confused, sometimes combative (a display of aggression) and sometimes would get agitated (feeling restless, uneasy, or disturbed, often with a strong urge to move around or act out). CNA 1 stated Resident 1 was blind and was unable to use a call light. CNA 1 stated the certified nursing assistants (in general) were required to make rounds (when someone goes to check on a resident) to monitor the resident. CNA 1 stated she (CNA1) did not document when she (CNA1) would make rounds and could not provide proof when she (CNA1) would do her rounds on Resident 1. CNA 1 stated Resident 1 was totally dependent (a person needs complete help from another person to do all or most of their everyday tasks) on the with care. CNA 1 stated Resident 1 was not safe to get up out of bed by herself. During a phone interview on 7/29/2025 at 1:06 PM with Resident 1's Family Member 1 (FAM 1), FAM 1 stated Resident 1 was blind and hard of hearing. FAM 1 stated he (FAM1) thought there was a disconnect between staff members at the facility because he (FAM 1) stated when he communicated something to one staff member, he (FAM 1) felt what he (FAM 1) communicated was not passed along to other staff members (unidentified). FAM 1 stated he (FAM1) thought 055157 Page 3 of 6 055157 07/29/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident 1 sustained her injury (fractured left hip) sometime between 7/21/2025 and 7/22/2025. FAM 1 stated the floor mats that were supposed to be placed around Resident 1's bed were not always present when he (FAM 1) would visit (unknown date) Resident 1. FAM 1 stated he (FAM 1) would sometimes noticed Resident 1's floor mats were placed up against the wall instead of around Resident 1's bed. During a concurrent interview and record review on 7/28/2025 at 1:19 PM with the Quality Assurance Nurse (QA a nurse who works to make sure patients get the best and safest care possible), Resident 1's Care Plan Report dated 5/16/2025 was reviewed. The QA nurse stated Resident 1 was at risk for elopement and required assistance with ambulation. The QA nurse stated the Care Plan Report did not indicate how often the nursing staff (in general) needed to monitor Resident 1's location (whereabouts). The QA nurse stated the Care Plan Report indicated nursing interventions included to monitor Resident 1's location (whereabouts) every __ (blank) min. The QA nurse stated the licensed nurses (in general) needed to add an intervention that indicated how many minutes Resident 1's location should have been monitored instead of leaving the number of minutes blank. The QA nurse stated the facility did not have a tool for documenting Resident 1's locations. The QA nurse stated Resident 1 was blind and confused. The QA nurse stated she (QA nurse) could not produce any documentation that Resident 1 knew how to use her (Resident 1) call light. The QA nurse stated Resident 1's floor mats were sometimes removed by the cleaning/maintenance staff (unidentified) to clean the floor when Resident 1 was up in a chair or out of the room. The QA nurse stated she (QA nurse) could not say how long the floor mats were removed from around Resident 1's bed. The QA nurse stated she (QA nurse) could not explain why the facility's staff (in general) did not see Resident 1 go(by t out of her (Resident 1's) bed and fell even though Resident 1's room was directly in front of the nursing station. During an interview on 7/28/2025 at 1:42 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was confused, hard of hearing, and blind. LVN 1 stated Resident 1 did not have the ability to use her call light. LVN 1 stated that even if the staff (in general) would give Resident 1 the call light Resident 1 would not use the call light. LVN 1 stated she (LVN1) could not explain why the facility created a care plan for Resident 1 to use a call light when Resident 1 did not have the ability to use it (call light). LVN 1 stated Resident 1 had a history of trying to get out of bed by herself and required frequent(unspecified) monitoring. LVN 1 stated the facility placed Resident 1 close to the nursing station and she (LVN1) would look inside Resident 1's room but did not document when she (LVN 1) would monitor Resident 1. LVN 1 stated if the facility did not document interventions, there was no proof the facility was monitoring Resident 1. LVN1 stated Resident 2 told her (LVN1) that Resident 1 fell (unspecified date and time). During a phone interview on 7/28/2025 at 2:06 PM with Family Member 1 (FM 1) and Family Member 2 (FM 2), FM 1 stated he (FM1) witness Resident 1's floor mats were not on the floor and were against the wall while Resident 1 was in her room. FM 2 stated she (FM2) had some safety concerns. FM 2 stated when she (FM2) would visit (unknow dates) Resident 1, she (FAM2) would see Resident 1 left alone and did not see the facility staff (in general) making rounds for approximately (about) one hour. FM 2 stated Resident 1's privacy curtains were usually drawn (by unidentified staff) closed around the bed) and Resident 1 was hard to see when the privacy curtains were drawn. During an interview on 7/28/2025 at 2:21 PM with Registered Nurse 1 (RN 1), RN 1 stated the facility gave Resident 1 a call light because it was the facility's standard to place the call light beside her (Resident 1). RN 1 stated giving Resident 1 a call light when she (Resident 1) could not use one was not an effective intervention because Resident 1 had not used the call light. When asked for proof that staff (in general) made rounds on Resident 1, RN 1 stated the facility documented when adult briefs (disposable underwear) were changed for Resident 1. RN 1 stated that 055157 Page 4 of 6 055157 07/29/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Actual harm Residents Affected - Few documentation of adult briefs was not the same as documentation of rounds being performed to monitor Resident 1 and could not provide documented proof rounds were made. RN 1 stated the facility considered using a bed alarm for Resident 1 but could not provide documented proof. During an interview on 7/28/2025 at 2:37 PM with Resident 2, Resident 2 stated she (Resident 2) could not remember when Resident 1 fell. Resident 2 stated she (Resident 2) saw Resident 1 fall and could not remember the date. Resident 2 preferred not to answer more questions. During an interview on 7/28/2025 at 3:50 PM with the facility's Physical Therapist (PT, is a healthcare provider who helps you improve how your body performs physical movements), the PT stated Resident 1 was at risk for falls due to her poor cognition, lack of balance deficit (difficulty staying steady on your feet), and lack of coordination. The PT stated Resident 1 was discharged from the physical therapy program and placed in the Restorative Nursing Assistant Program (RNA specially trained certified nursing assistants [CNAs] who help residents in healthcare facilities regain or maintain their ability to perform daily tasks like bathing, dressing, and eating). During an interview on 7/28/2025 at 4 PM with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated when she (RNA 1) worked with Resident 1, she (RNA 1) required the assistance of another RNA while working with Resident 1 (unknown date) because Resident 1 was sometimes confused and resistive to therapy. RNA 1 stated the last time she worked with Resident 1 was on 7/22/2025 and reported to the charge nurse (unidentified) Resident 1 was resistive to therapy. RNA 1 stated the charge nurse (unidentified) medicated (unidentified medication) Resident 1. RNA 1 stated 40 minutes after the charge nurse (unidentified) medicated Resident 1, RNA 1 try to work with Resident 1 again but Resident 1 did not cooperate. During an interview on 7/28/2025 at 4:07PM with the Social Services Director (SSD), the SSD stated Resident 1 had dementia and was often disoriented and had to work with Resident 1's family (FM 1 and FM 2). During an interview on 7/28/2025 at 4:23 PM with the facility's ADM and DON, the ADM stated she (ADM) could not say if staff (in general) had a line of sight (unobstructed view when looking from one point to another) of Resident 1 when Resident 1's privacy curtain was drawn (by unidentified staff). The DON stated if Resident 1's floor mats were not on the floor; Resident 1 could fall and injure herself. The DON stated the licensed nurse's (in general) rounds were not documented by the facility. The DON stated giving a confused resident (in general) a call light and expecting them to use it was not prudent (sensible) because Resident 1 could not be taught to use it. The DON stated if the facility did not document the facility's monitoring of Resident 1's location, the facility did not have proof that the monitoring was done. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 1/2025, the P&P indicated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated the staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic (done or acting according to a fixed plan or system) evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e to try one or a few at a time, rather than many at once). The P&P indicated in conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis as applicable) to try to minimize serious consequences of falling. The P&P indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. During a review the facility's policy and procedure (P&P) titled Elopement Policy & Procedure, dated 1/2025, the P&P indicated the safety of all residents is the primary care standard at the facility. Impaired judgement, perception, and thought processes of cognitively impaired persons make the residents at a 055157 Page 5 of 6 055157 07/29/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0689 Level of Harm - Actual harm Residents Affected - Few higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures and staff and visitor education have been put into place to maximize resident safety. During a review of the facility policy and procedures (P&P), titled, Routine Resident Checks, revised 1/2025, the P&P indicated, Routine resident checks shall be made to assure that the resident's safety and well-being are maintained.1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least every 2 hours throughout each 24-hour shift.2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each checks. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.) 055157 Page 6 of 6