Health inspection·August 23, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Minimum Data Set Nurse (MDS Nurse - a nurse to documents using the resident assessment tool), the Social Service Assistant, and the Maintenance Supervisor (MS). The acceptable IJRP included the following summarized actions: On 8/21/2025, the facility readmitted Resident 1 and the admitting nurse (unidentified) updated Resident 1's elopement assessment and diagnoses. The elopement assessment indicated Resident 1 was at high-risk for elopement and the facility placed Resident 1 with one CNA (unidentified) at all times. On 8/21/2025, the DSD provided an in-service regarding elopement prevention and response to fifty-five staff(unidentified) with a plan for the DSD to perform in-services for staff who were on vacation, off schedule, and for new hires. On 8/21/2025, the MDS nurse and the facility's Medical Records (MR) staff identified four residents who were at high-risk for elopement. The facility ensured the care plans and assessments were in place for the four residents. On 8/22/2025, the facility updated Resident 1's care plan to include Resident 1 was at risk for elopement and had a history of elopement. On 8/22/2025, an emergency Quality Assurance and Performance Improvement (QAPI, a program that healthcare providers use to constantly check and improve the quality of their services) meeting was held with the facility's Medical Director, Department Heads (leaders of a specific group of people within a company, who makes sure that team's work gets done smoothly and on time), and the Administrator Consultant (ADMC) to address the facility's systemic issues (the problems with the facility's systems) on elopement. On 8/22/2025, the ADMC and the ADM updated the Audible Battery-Operated Door Alarms Policy and Procedure (P&P). On 8/22/2025, the ADMC provided an in-service to thirty-nine staff including licensed nurses, CNAs, dietary, and housekeeping staff on the Audible Battery-Operated Door Alams P&P to ensure staff were aware of the times the door alarms were to be activated. The facility planned for the DSD or designee (someone who has been officially chosen) to provide an in-service for staff on vacation before the start of the staff's first shift back from vacation. The facility planned to in-service new hires before the first scheduled shift. Current staff, who were not on schedule, would be in-serviced before the start of their first shift back on schedule. On 8/22/2025, the facility created an elopement binder with a list of residents who were at high-risk for elopement and placed the binder in each nursing station. On 8/22/2025, the DON provided a one-on-one in-service to Registered Nurse 1 (RN 1) on the Elopement Prevention and Audible Alarm policies. On 8/22/2025, the DON provided a one-on-one in-service to Registered Nurse 2 (RN 2) regarding elopement prevention.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 7/4/2025 and readmitted the resident on 8/21/2025 with diagnoses that included dementia, weakness, hypertension (HTN-high blood pressure), and history of falling. During a review of Resident 1's Risk of Elopement assessment dated [DATE], the Risk of Elopement Assessment indicated RN1 completed the assessment. The Risk of Elopement Assessment indicated Resident 1 was not at risk for elopement. The Risk of Elopement Assessment indicated Resident 1 was ambulatory (able to walk). The Risk of Elopement Assessment indicated Resident 1 did not have any indications of a diagnosis of dementia. The Risk of Elopement Assessment indicated if Resident 1 was ambulatory and had a diagnosis of dementia, the facility was supposed to initiate (start) a care plan for potential elopement. During a review of Resident 1's Care Plan Report dated 7/4/2025, the Care Plan Report indicated Resident 1 was at risk for falls related to the history of falls, dementia, general weakness, and hospice (care for people who are nearing the end-of-life prioritizing comfort and quality of life by reducing pain and suffering). The Care Plan Report indicated the intervention was to implement fall precautions (unidentified). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/10/2025, the MDS indicated Resident 1 usually could make himself understood and had the ability to understand others. The MDS indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055157 If continuation sheet Page 2 of 5 Printed: 05/15/2026 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 055157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Resident 1's had severe cognitive (ability to think and process information) impairment (loss). During a review of Resident 1's History and Physical (H&P) dated 7/27/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. During a review of Resident 1's Emergency Department (ED) GACH note dated 8/20/2025 at 4:28 AM, the ED GACH note indicated the EMS arrived with Resident 1 from a public area (unidentified) with complaints of unsteady gait, unable to ambulate, and left knee pain, witnessed by bystanders (unidentified). During a review of Resident 1's Progress Notes dated 8/20/2025 at 5 AM, the Progress Notes (documented by LVN2) indicated Resident 1 woke up around 2:40 AM. The Progress Notes indicated at 3:20 AM a charge nurse (LVN 3) found out that Resident 1 tried to go out (unidentified) and he (LVN3) called him (LVN2) to put Resident 1 in Resident 1's room. The Progress Notes indicated RN2 and LVN 2 gave Resident 1 emotional support. The Progress Notes indicated at 3:45 AM a CNA (CNA8) found that Resident 1 had disappeared. The Progress Notes indicated all nurses (unidentified), and CNAs (unidentified) could not find Resident 1 inside or outside the facility. During a review of Resident 1's ED note dated 8/20/2025 at 7:28 AM, the ED note indicated Resident 1 presented to the emergency room with the EMS for evaluation of unsteady gait and confusion. The ED note indicated Resident 1 was found next to a car in a standing position and no other information was known. The ED note indicated Resident 1 was unable to give any additional informationDuring a review of Resident 1's Progress Notes dated 8/20/2025 at 9:32 AM, the Progress Notes indicated the facility received a report from the local police department that Resident 1 was found at the GACH. During a review of Resident 1's Progress Notes dated 8/20/2025 at 10 AM, the Progress Note indicated the facility was able to verify Resident 1 was brought to the GACH via emergency services and the GACH planned to admit Resident 1 to the GACH. During an interview on 8/20/2025 at 1:11 PM with the GACH emergency room (ER ) Registered Nurse (ERRN), the ERRN stated Resident 1 was admitted to the GACH due to a mental status change (when a person's thinking, awareness, or behavior suddenly shifts from their normal state, often described as being confused, disoriented, agitated, or having trouble focusing). During an interview on 8/20/2025 at 3:40 PM with CNA 1, CNA 1 stated Resident 1 would attempt to leave the facility in general (unidentified date and time) and that she (CNA1) notified LVN 1. During a concurrent interview and record review on 8/20/2025 at 3:45 PM with LVN 1 and RN 5, Resident 1's Risk of Elopement dated 7/4/2025 was reviewed. LVN 1 and RN 5 stated Resident 1 had a diagnosis of dementia, and the licensed nurse (RN1) should have identified Resident 1 as a risk for elopement. During a concurrent interview and record review on 8/20/2025 at 4:25 PM with the ADM and the DON, the facility's admission Inquiry form (medical history prior to the facility's admission), dated 7/2/2025 was reviewed. The ADM and DON stated the admission Inquiry form indicated Resident 1 had dementia. The ADM and DON stated the nurse (RN 1) who performed the Risk of Elopement should have identified Resident 1 as an elopement risk. During an interview on 8/20/2025 at 4:42 PM with LVN 2, LVN 2 stated Resident 1 tried to get out of bed on the night of his (Resident 1) elopement (8/20/2025). LVN 2 stated the other charge nurse (unidentified) whose name he (LVN2) did not know, noticed Resident 1 tried to leave the facility. LVN 2 stated a CNA whose name LVN 2 did not know, and a charge nurse whose name LVN 2 did not know, took Resident 1 back to Resident 1's room. LVN 2 stated 30 minutes later the staff (unidentified) could not locate Resident 1. LVN 2 stated he (LVN2) did not hear any door alarms go off. During an interview on 8/20/2025 at 4:46 PM with RN 2, RN 2 stated she (RN2) redirected Resident 1 and LVN 3 brought Resident 1 back to his bed in the early morning of 8/20/2025. RN 2 stated 15 minutes later the facility staff (unidentified) could not locate Resident 1. RN 2 stated she (RN2) could not explain why the alarms did not sound on the morning of 8/20/2025 and Resident 1 eloped from the facility. During an observation on 8/21/2025 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055157 If continuation sheet Page 3 of 5 Printed: 05/15/2026 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 055157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 5:50 AM, CNA3 was observed sitting in front of a room next to one of the exits to the front of the facility. The surveyor knocked and CNA 3 came to the front exit/entrance to the facility facing a street avenue and opened the door from the inside and the door alarm did not sound. There were no staff observed at the front desk. During a concurrent observation and interview on 8/21/2025 at 5:52 AM, with RN 1 and CNA 4, the facility's front door entrance/exit facing a street avenue did not sound. RN 1 stated she (RN1) disarmed the front door entrance/exit at 4 am because the housekeeping staff (unidentified) came in at 4 AM. RN 1 stated the facility would disarm (turn off) the alarm in the front door entrance/exit for a long time, (RN 1 could not give a specific timeframe). Station 1 exit door was open, and the alarm did not sound. RN 1 stated she (RN 1) left station 1 exit door unarmed to let the housekeeping staff (unidentified) inside. RN 1 stated if the front door was not armed, a resident (in general) could leave the facility without the staff (in general) knowing. RN 1 stated the facility's policy (unidentified) allowed her (RN1) to disarm the alarms (in general) at 4 am to let the housekeeping staff inside the facility. During a concurrent interview and record review on 8/21/2025 at 5:52 AM, with RN 1, the facility's policy and procedure (P&P) Audible Battery Operated Door Alarms, dated 1/2023, RN1 stated the P&P indicated the front door alarm should be armed from 10 PM to 7 AM. RN 1 stated the front door was not armed because staff (in general) would go in and out of the facility. During an observation on 8/21/2025 at 5:55 AM, the front door alarm did not sound when the surveyor opened the door. During an observation on 8/21/2025 at 5:57 AM, the station 1 back exit door was wide open without an alarm sound. During an interview on 8/21/2025 at 6:50 AM with CNA 4, CNA 4 stated the RN Supervisors (in general) would disarm the alarms for station 1 back door and the front lobby door alarms around 4 am to let housekeeping staff (in general) inside the facility. CNA 4 stated RN 2 would disarm the alarms around 4 am. During an interview on 8/21/2025 at 7 AM with CNA 5, CNA 6, and the Laundry Aid (LA), CNA 5, CNA 6, and LA, they all stated that the night RN Supervisors (in general) would disarm the facility's alarms (in general). During an interview on 8/21/2025 at 7:05 AM with Housekeeper 1 (HK 1), HK 2, and HK 3, HK 1, HK 2, and HK 3 they all stated the night RN Supervisor (in general) would disarm the alarms (in general) in the early morning to let them (housekeeping staff) into the facility. During an interview on 8/21/2025 at 7:20 AM with the IP, the IP stated he (IP) did not know why the doors were not armed on 8/20/2025 in reference to Resident 1's elopement. During an interview on 8/21/2025 at 9:02 AM with Resident 1's Power of Attorney 1 (POA 1 - a legal document where a trusted person makes healthcare decisions for you if you become unable to make them yourself), POA1 stated Resident 1 had a history of trying to elope from two previous GACHs (unidentified) on two previous occasions. The POA1 stated Resident 1 was very good at escaping. POA 1 stated Resident 1 lived alone and could no longer take care of himself (Resident 1). POA 1 stated the facility did not ask him (POA 1) about Resident 1's history of attempting to elope. During a concurrent interview and record review on 8/21/2025 at 12:05 PM with RN 3, DON, and the ADM, Resident 1's all care plans (in general) were reviewed. RN 3 and the DON stated there was no care plan for elopement for Resident 1. During an interview on 8/21/2025 at 3:44 PM with the ADM, the ADM stated Resident 1 eloped from the facility on 8/20/2025 at 3:45 AM. During an interview on 8/21/2025 at 4:27 PM with the ADM, the ADM stated CNA 8 reported Resident 1went missing from the facility on the morning of 8/20/2025. During a review of the facility's Audible Battery-Operated Door Alarm P&P dated 1/2023, the P&P indicated the facility provides a safe environment for all staff and residents. The P&P indicated the RN supervisor on duty was responsible for ensuring the alarms are enabled. The P&P indicated the nursing staff should be notified if the alarms are not working and to check on resident's who are at high risk for elopement frequently. During a review of the facility's Elopement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055157 If continuation sheet Page 4 of 5 Printed: 05/15/2026 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 055157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 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 - Immediate jeopardy to resident health or safety P&P dated 1/2025, the P&P indicated impaired (decreased) judgment (mental abilities that help a person understand and decide on something), perception (awareness), and thought processes of cognitively impaired persons make the residents at high risk for elopement. The P&P indicated precautions, procedures (unidentified) and staff and visitor education have been put into place to maximize resident safety. The P&P did not indicate how to prevent an elopement. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055157 If continuation sheet Page 5 of 5