Health inspection·August 14, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services for two of five samples Residents (Residents 1 and 4) in accordance with professional standards of practice in order to meet resident's physical, mental, and psychosocial needs by failing to:1. Notify the physician about ineffective treatments for a generalized body rash as indicated in the Resident 1 care plan titled, alteration in skin as manifested by generalized body rash, initiated 7/29/2025.2. Implement a care plan for a rash on the left inner thigh for Resident 4 to monitor for effectiveness of the treatment.These deficient practices resulted in significant physical and psychosocial distress for both residents (Residents 1 and 4), including intense itching, insomnia, anxiety, depression, and reduced participation in daily activities. 1. During a review of Resident 1's Record of admission indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). During a review of Resident 1's late entry nursing note dated 5/3/2025 at 7:50 pm indicated, Tx (treatment): Apply Vitamin A&D (primarily used as a skin protectant and moisturizer for treating and preventing a variety of skin irritations. The combination of vitamins A and D, often with petrolatum and lanolin, creates a protective barrier on the skin while also promoting healing) to left upper extremity (arm) due to skin discoloration. During a review of Resident 1's physician orders dated 5/5/2025 at 2:01 pm indicated, trazodone HCl Oral Tablet 50 MG (Trazodone HCl- antidepressant with multiple uses, including Food and Drug Administration-approved treatment for depression and off-label use for insomnia and anxiety), Give one tablet by mouth at bedtime for depression m/b (manifested by) inability to sleep. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, indicated, Resident 1 was cognitively intact (a person's brain functions related to thinking, learning, and memory are intact, allowing them to effectively manage daily life without significant cognitive impairment or decline). The same MDS indicated Resident 1 required between partial/moderate-to-substantial/maximal assistance for all Activities of Daily Living (ADLs- eating, oral hygiene, toileting hygiene, shower/bathe self, upper & lower body dressing, personal hygiene, putting on/taking off footwear). During a review of Resident 1's physician orders dated 6/19/2025 indicated, Hydroxyzine HCl (an antihistamine used to treat itching, hives, and anxiety) Tablet 25 MG, give two tablets by mouth every eight hours as needed for general itchiness at back side During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) progress note dated 7/29/2025, indicated, Noted with generalized body skin rash (Lower extremities, upper extremities, back area) with sites of multiple small, irregular in shape skin redness, with slight skin elevations with Residents Affected - Some Page 1 of 3 055157 055157 08/14/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some periods of itchiness complain. Primary doctor made aware. With treatment order noted and carried out. During a review of a physician's order dated 7/29/2025 indicated an order for hydrocortisone 1% cream to be applied to the affected area every shift until 8/1/2025. During a review of a care plan titled, alteration in skin as manifested by generalized body rash, initiated 7/29/2025 with interventions which included to notify physician if treatments were not effective. During a review of Resident 1's physician orders dated 7/30/2025 at 2:35 pm indicated, dermatology (branch of medicine concerned with the diagnosis and treatment of skin disorders) consult due to generalized body rash. The same orders indicated for skin scrape d/t (due to) generalized body rash and contact precautions due to suspected rash. During an interview with Certified Nursing Assistant (CNA) 1 on 8/12/2025 at 4:13 pm, CNA 1 stated that she had observed that Resident 1 had a generalized itchy rash all over her (Resident 1) body. CNA 1 stated that Resident 1 complained about the intense itch which kept her from sleeping at night. CNA 1 stated that Resident 1 frequently scratched her body throughout the day. During a concurrent observation and interview with Resident 1 on 8/12/2025 at 10:57 am, Resident 1 was observed sitting on stationary equipment in the physical therapy room. Resident 1 was scratching with increasing frequency and intensity throughout the interview and appeared anxious, upset, and agitated stating, I am so sick and tired of being this way. She was observed to have red and grayish scattered, raised rash to her right arm, left arm, and chest. The resident stated that she also had the same rash to her right leg. She stated that even though she was scratching and very uncomfortable right now, it was exponentially worse at night to the point that she was unable to sleep due to the intensity of the itchiness. Resident 1 stated as she started to blink rapidly with red glossy eyes as if preventing her tears from running down her cheeks that she had been begging staff to find a medication/cream that worked. She stated that she felt ignored, anxious and now had insomnia because of the discomfort. She stated that the felt so helpless that she had run out of how to express herself and now just curses. She stated that she was prescribed trazodone for sleep which helped her fall asleep for a couple of hours before the intense itch becomes noticeable again. The resident stated she felt that staff did not do good in listening to her nor did they thoroughly explain what treatments were given, why they continued to give her the same treatments that did not work in the first place. The resident stated that she had felt staff just did things to try and keep her quiet. During an interview with the Treatment Nurse (TN) on 8/13/2025 at 12:10 pm, TN admitted that Resident 1 had a recurrent generalized rash which had just reappeared on 7/29/2025. TN stated that Resident 1 was prescribed an anti-itch cream and confirmed that Resident 1 complained about the intense itching at night. TN stated that Resident 1 was prescribed trazodone which he stated was not as effective because the lack of sleep was due to the itching instead of ordinary insomnia. TN admitted that the current treatments were not effective for Resident 1 but that the physician had not been notified. TN stated that he was aware that it would be hard on the resident and cause lack of sleep and potentially cause the resident to feel depressed. 2. During a review of Resident 4's Record of admission indicated, Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain), DM and HTN. During a review of Resident 4's MDS dated [DATE], indicated, Resident 4 had severe cognitive impairments (a significant loss of the ability to think, learn, remember, concentrate, or make decisions, to the point that the person cannot live independently). The same MDS indicated Resident 4 required between partial/moderate-to-substantial/maximal assistance for ADLs. A review of Resident 4's history and physical (H&P- a formal medical document and assessment process where a healthcare provider 055157 Page 2 of 3 055157 08/14/2025 Virgil Rehabilitation & Skilled Nursing Center 975 North Virgil Avenue Los Angeles, CA 90029

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gathers information through a patient interview [the history] and a hands-on examination [the physical exam] to understand the patient's health, diagnose illness, and create a treatment plan) dated 6/22/2025, indicated Resident 4 had fluctuating capacity to understand and make decisions. During a review of a care plan for alteration in skin as manifested by rash/redness site to the left inner thigh initiated on 8/7/2025 listed interventions which included give ordered treatment and monitor for effectiveness. During a concurrent observation and interview of Resident 4 on 8/13/2025 at 10:38 am, Resident 4 was dressed in a floral dress, sitting at her bedside watching tv. Resident 4 observed scratching her chest, abdomen, legs, arms, palm of her hands, her flank and her back as she spoke with the surveyor. Resident 4 stated that she had had this rash for several weeks as tears started to run down her face. Resident 4 stated that she had been complaining to the facility staff about the intense itching which has affected how she interacts in the facility. She stated that she is unable to sleep, which made her feel exhausted throughout the day, making it impossible to participate in her daily activities. Resident 4 stated that she felt unheard, anxious, depressed and in a constant state of stress. Resident 4 was observed to have widespread rash of red bumps, small blisters, or scaly patches, often accompanied by tiny, wavy burrows especially on the palms of her hands and the webs of her fingers During an interview with the TN on 8/13/2025 at 12:20 pm, TN stated that Resident 4 complained of itching to her right chest as well as bilateral inner thighs. TN stated that he was not aware that Resident 4 was itchy at night because Resident 4 was mostly Spanish speaking. During an interview with the Director of Nursing (DON), on 8/12/2025 at 4:37 pm, the DON stated that if residents are unable to sleep, they may get restless and possibly depressed. The DON stated the physician must be called if the treatment is not effective. During an interview with the Medical Director (MD), on 8/14/2025 at 4:21 pm, the MD stated that the facility staff are expected to contact the physician whenever there is a change in condition such as rashes. The MD stated that staff must report to the physician's if the ordered treatments are not effective to ensure the resident's quality of life is maintained. The MD stated that treating the underlying cause if insomnia is paramount and must have been investigated further instead of treating a symptom. During a review of the facility's policy and procedures (P&P) titled, Change of Condition Policy, reviewed 1/2025, the P&P indicated, The facility shall notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status.The Nurse Supervisor shall notify the resident's attending physician, consistent with medical director and physician policies, when:- There is a significant change in the resident's physical, mental, or psychosocial status;- There is a need to alter the resident's treatment significantly. 055157 Page 3 of 3